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Need medication advice for a newbie

13 posts in this topic

My husband was diagnosed with PD last month after a DaTScan to confirm suspicion.  We are taking your advice to seek a movement disorder specialist, but the first appointment available for a new patient is in September (!!)  (We're on the waiting list for any cancellations.)  We have a general neurologist but I'm anxious to get under the care of a specialist, and would much rather prefer starting at ground zero with that specialist.  So while we're in limbo, we feel the pressure of starting some kind of treatment with the general neurologist to address symptoms.  I've been reading your info on medication choices to educate us.  My question is:  Given the following patient profile, which medication would you recommend he start with?

Male; age 57; Very good health; Mentally sharp; Generally medicine-averse; Still working (computer programmer-- lots of keyboard typing) with hopefully several more years of working; tremor in right hand that started maybe about a year ago but has gotten progressively worse-- to the point of now wanting medication; some stiffness in right hand with loss of dexterity with keyboard typing (this is the part he really wants relief with, and has said that he can live with some tremor if need be); no compulsive behaviors; currently taking Ocuvite (multivitamin with Lutein, Zeaxanthin, and Lycopene to hopefully prevent macular degeneration that his mom has); he has other PD symptoms like lack of arm swinging and others that lead us to get a DatScan (I can list specific other symptoms if need be, but the "presenting" symptom is hand tremor.)

Thank you in advance for your "specialist" advice!

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There is no right way to do this, but usually I start with daily exercise and a MAO-B inhibitor.  If the tremor persists then I usually add Sinemet 25/100 1/2 a tab every 5 hours or so and each week increase by a half tab until the tremor comes under control...

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Thank you for your kindness in replying!

Is the general strategy to start with "something other" than Sinemet (for examples, MAO-B inhibitor or a dopamine agonist), and then add Sinemet when the other becomes less effective (or ineffective)?  In effect, saving Sinemet as the 'big guns?"

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Not necessarily.  We will start with Sinemet if the symptoms are severe and disabling.....we choose cases by case.

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Thanks for your reply!   

We don’t know how to qualify “severe or disabled” in PD terms, but he just cut up raw chicken using his tremoring hand before cooking supper, so we’re guessing he’s not severe or disabled.   
According to the usage chart in the Parkinson’s Disease Medications pdf, it looks like MAO-B inhibitors aren’t as widely used compared to Sinemet, so I’m wondering if our general neurologist considers it to be a tool in his toolkit of options.  His only suggestion so far has been to start “the medicine" (Sinemet.)  In looking at the info in the pdf, we have a choice of two MAO-B inhibitors: Selegiline and Rasagiline, with Rasagiline possibly being preferred.
My questions are:
1.       Is Rasagiline the preferred MAO-B inhibitor?
2.       If we ascertain that the general neurologist doesn’t have options other than Sinemet in his working toolkit, how do we get other medication options to be considered?   We have an appointment with him this week. 

 

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Rasagiline and generic selegiline seem to give about equivalent symptomatic benefits in trials.  Certainly Sinemet or dopamine agonists would be the next step or both if the tremor remains an issue.  I usually use Sinemet as the next step in situations such as yours.  If you can't get all the options on the table maybe you could consider a second opinion as the choice should be yours!

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Thank you very much.  We will take the Parkinson's Disease Medications info with us to the neurologist appointment and discuss all of our options.  We really appreciate your input.  

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Sinemet is ok to start with and we use it all the time as the first line.

If you use a dopamine agonist then we recommend monitoring for impulse control and other side effects.

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The neurologist took a hard line "no" to MAO-B inhibitors.  He is willing to try a dopamine agonist though, even though he says he'd typically do that for someone younger.  I think 57 is still "young." :-)   The doctor said the symptoms are mild, but the tremor and finger rigidity are interfering with my husband's life, with everyone (at work and after-work) watching his hand tremor and in his use of his keyboard.  

After much discussion, we are proceeding with generic Sinemet, 1 pill per day for a week, then adding another pill after 5 hours for a week.  if there's not enough relief, then we add another pill after another five hours (3 pills per day.)  I was very glad to get your last update saying that Sinemet is ok to start with.  I still feel uncomfortable that we're not trying anything else, but we all agree that we need to progress down the medication road.  I just hope that we're not doing something that the movement disorder specialist will feel the need to undo when we finally get to the appointment in September.  

The pharmacy filled the Rx with generic Sinemet, which I understand can be off by 30% either way.  Should we insist on the name brand Sinemet in order to get some good data on Sinemet's efficacy with my husband in preparation for seeing the movement disorder specialist?

Thanks again for your kind help.

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I would not insist on brand Sinemet.  You may want to try 1 tablet then 1.5 tablets and then 2 tablets and choose the best dose (instead of jumping from 1 to 2 tabs.

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Ok, thanks again!

1st week:  1 tablet once a day in the morning.

2nd week:  1 tablet in the morning as usual, then five hours later take 0.5 tablet.  Each day for the week.

3rd week:  (If needed):  Increase second dose to 1 full tablet  

I will start a spreadsheet to capture any data.  

 

 

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My husband has been taking Sinemet for a few years now at a rate of 4 or 5 per day.  His Doctor wants to start him on Exelon 4.6MG/24H Patch as he didn't score as well on his memory test as he has in the past, and he wasn't walking as well either.  Also he has had 2 falls this year, but is a very active man of 81 years old. We have 20 acres and he likes to get out and mow and walk around.   He has heart issues and takes Carvedilol 12.5mg once daily.  I did read about the Exelon and it mentioned possible problems with the Exelon and Carvedilol.  Is that a common risk?  Also, I wanted to ask if it has been your experience that Exelon has good results for memory and movement.  I did get the prescription filled and it was VERY expensive.  If it helps a lot, it would be worth taking, but if it didn't help that much, it wouldn't.  Your opinion would be appreciated.  Thanks.

Edited by Geri

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I do not have any experience with that cardiac drug and exelon so I would have to advise you to ask your pharmacist and then circle back to your doc.

I personally use Aricept and Exelon interchange-ably if one is cheaper than another and I am not married to patch versus pill.....it may provide mild memory improvement in some patients.

Reading the story I wonder if you and your doc should dose the Sinemet at closer intervals and make sure each dose is correct for his symptoms and side effects....

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