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Timing of Sinemet vs increased dose

18 posts in this topic

I'm wondering about how to determine whether my Sinemet dosing intervals simply need to be shortened vs adding more to each dose and which strategy to try first and for how long. My Sinemet seems to wear off before the next dose, but at the same time, the afternoon doses don't really seem to kick in much at all. Morning dose works best - maybe because it's on a completely empty stomach, although I try to wait an hour after eating in the afternoon. Which leads me to one final question - is it better to take Sinemet exactly on time even if it's closer than an hour to food intake? Sometimes I delay15-30 minutes if my dose is due too close to when I've eaten. I don't know which is worse - the proximity to food or the delay. Thank you.

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I personally prefer to tell patients to stay on time (exactly) even if slightly interfering with eating.  I would likely move the interval 1 hour closer to start and assess the effects of this change.  If you still have dose failures then in a few weeks you may try to also increase dose and keep closer intervals.  These are suggestions for you and your doc.

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I have similar questions regarding increasing the dose or increasing the interval. I have been diagnosed for almost two years and have been taking 3 25/100 Sinemet ER at 5:30 am, 11 am, and 5 pm until about the last month. In mid-November, I started feeling like I was never really "on" throughout the day. My tremor and stiffness did not seem to respond to the first dose.

 

After getting the ok from my neurologist to try an increased dosage, I have been experimenting with my dosage for the last month to try to better control my tremor and stiffness. I had a bottle of unused regular Sinemet 25/100s and began taking a half a dose with my first dose of the morning. The tremor and stiffness was under control, but I could feel it wearing off by about 10 am and 4 pm. I tried taking an extra quarter or half dose of regular Sinemet with my second and third dose of Sinemet ER and the symptoms were better controlled, but I would still wear off somewhat before my next dose. I then moved by second and third dose to 10 am and 3 am and added half dose of 25/100 Sinemet ER at 7:30pm. My tremor is under control after my first dose but is only reduced by maybe 80 percent for the rest of the day.

 

How much symptom control do you aim for? Complete control regardless of the dose or take just enough levodopa to make them manageable?

 

My neurologist changed my prescription this week to 4 Sinemet ER's and 1/2 Sinemet per day with the first dose. What would be your recommendation for the dosing intervals? I wake at 5:30 and normally go to bed by 10pm. I thought I would try the 1.5 dose at 5:30 and then 1 dose at 9:30, 1:30, and 5:30.

 

Is it better to take lower doses closer together than larger doses farther apart?

 

Would the more frequent lower doses reduce the potential for dyskinesia vs the larger less frequent doses?

 

Thank you for all that you do to help guide us though this PD journey.

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I would personally use more frequent and consistent dosing.  Rarely does a patient require more than 300mg per dose.  Many times simply moving doses to every 3 or 4 hours will alleviate the issues.  For some patients this may translate into complete tremor control and for others there may be a partial benefit.  Lower and more frequent doses are associated with less dyskinesia.

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Thank you for the reply. I have been taking 1 25/100 Sinemet ER at 5:30, 9:30, 1:30, and 5:30 with 1/2 Sinemet 25/100 with my first dose for just over a week and the symptoms are much better than they were spaced out at 6 hour increments. I still have a minor tremor, but it is not bothersome enough to increase the dose at this time.

 

Thanks again.

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It is so great to hear that you are doing better.  Let us know if we can help with other things in the future.

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In fact in some patients it will last even less than 4 hours....

 

What we do is dose all the way until bedtime.  If patients awaken at night and can't get back to sleep we ask them to re-dose.  In some cases we also add a sleeping medication.

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I seem to feel better and have fewer symptoms after my last dose of the day. I can usually fall asleep by 10 or 11 without much tremor or stiffness, and I can usually fall back to sleep if I wake at night. I did have to take an extra dose last week when I stayed up with a family member all night at the ER. The extra half dose in the morning seems to address my symptoms rather quickly.

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I personally prefer to tell patients to stay on time (exactly) even if slightly interfering with eating. I would likely move the interval 1 hour closer to start and assess the effects of this change. If you still have dose failures then in a few weeks you may try to also increase dose and keep closer intervals. These are suggestions for you and your doc.

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Dr Okun I am very interested to know why you recommend what sounds like strict adherence to a Med schedule (ie despite meal timing etc). I have heard this before. Do you think our bodies get "used" to a med schedule and therefore perform accordingly? ((If so then maybe it's better not "train" our bodies to be off lol)

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I am just doing what works for the majority of patients.....however one size does not fit all and if it works the other way who am I to disagree?  Make sense?  I think we should be open to the best solution and not too dogmatic.

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I'm wondering about balancing increased Sinemet dose with increasing dyskinesia, while dose still doesn't really seem to kick in. I feel I am really under medicated but as I've gradually increased my immediate release Sinemet 25/100 from 1 to 1.5 pills per dose to current level of 1.5, 2 pills , and 1.5 - 3.5 hours apart plus 1 CR in the evening, I can't say I notice that much on time (even when I take the 2 pills mid-day. ) My goal was to increase to 2 pills 3 x per day plus CR in the evening but as I've already noticed some increased dyskinesia without much if any improvement in symptoms when I take 2 Sinemet, I've been reluctant to increase the dose . I also have extensive bloating late in the day (gone by next morning), so I'm wondering if there could be a gastric emptying issue. Also, based on other comments posted, wondering if using CR throughout the day possibly might be more effective . Thanks.

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It is certainly possible that CR could reduce dyskinesia and improve on symptoms and this occasionally works in our practice though not as much as you would think.  Gastric emptying is a good thought and you could get a gastric emptying study.  Duopa pumps and DBS can be an option for some patients.

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My question is this regarding dosing.  My husband has been diagnosed 5 yrs now.  He is now taking 1 25/100 every two hours, except for first thing in the morning.  He takes 1 1/2 at 6am, takes the dog for his walk and by the time he gets home at 6:18, his medicine starts to kick in.  For him, this means that he gets extreme dyskinesia and tremors, which last till 7am.  Then he takes 1 1/4 at 8am, and we go through the same thing till 9am or so, usually by 9:30 he is ok.  Then he takes 1 25/100 at 10am, 12pm and 2pm.  From 10-2pm he is usually pretty good with mild kick ins after his meds.  But 2pm, he gets the severe dyskenesia again, or tremors or both.  He has tried going longer than 2 hours, but usually ends up getting a craving for the medicine and gets stiff and hard to move.  Needless to say, he doesn't get to do much and has little social life.  Rides his recumbant trike at 2pm and can peddle this even when legs shaking but that is mostly it.  Thought the carbadopa-levodopa was supposed to ease the tremors but for him, it seems to cause it.  It is a conundrum!  Any thoughts on this?  Dr recommeded the Duopa pump but he does not want surgery for the Duopa pump or DBS unless no other option.

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Sometimes we add amantadine for this issue.  Also, lowering the morning doses slightly or trying CR could be an option.  Most of these cases do well with DBS.  The pump may also be helpful.

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