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PegC

Parkinsonism versus A Parkinson's Diagnosis

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Hello Doctor,

My husband is 68 yrs old. His is extremely active, healthy, fit. He was around solvents and adhesive for much of his early career as a flooring contractor. He began suffering tremors, loss of smell, constipation all around age 62 along with other typical PD symptoms. We had several misdiagnosis along the way of essential tremors but recently with a new neurologist it was believed to be Parkinson's based on a DAT Scan.

He is currently on Azilect and we on Neurpro 4 MGs(build up to 4) for about a month with only a slight effect on his tremor. (not sure if we are imagining an improvement)

Our neurologist suggested a dopamine challenge - one pill over a 3 hour period. He was monitored and we all saw no real decrease in his tremor. Our neurologist is fairly certain based on his lack of response to the levdopa/caridopa, that he falls under the Parkinsonism umbrella.

My question - Is the one pill a true test or should be try a second test at home or a full month on Ldopa/Caridopa... which the Dr. said we could if we felt we wanted to.

I understand there are several diseases that fall under the umbrella of Parkinsonism and they are hard to confirm but also understand that DBS and any drugs that help with tremor would not be useful. His only real issue currently is the tremor and some lack of flexibility.

He was rated stage one  on the scale as well. Can you elaborate on confirming a diagnosis, disease progression, drug options and why DBS is not an option with Parkinsonism. Thank you for you insights. 

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Great question.  Response to tremor on a dopamine challenge does not inform the diagnosis of Parkinson's disease.  It turns out 20-40% of patients may have an incomplete response to tremor after dopamine.  Also, in your case 1 pill may indeed not be enough.

We usually recommend seeing a movement disorders trained or experienced neurologist if available and titrating the dose slowly looking for improvement.  Everyone is different and the tremor may likely improve or resolve at higher doses.  I hope that is helpful.

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Hello again Dr. Okun,

Yes we are in fact seeing a highly recommmended movement disorder specialist. He suggested if we wanted to confirm Parkinsonism, that we could try the dopamine for a month (Simemet) at 25-100 Tab one per day to see if the tremor responds. We had not planned on going on dopamine yet since he is so early in his diagnosis and stages... so it's more about options down the road.

I thinkk my real question is after one month, if no response is seen,  are then pretty certain it is Parkinsonism and therefore dopamine is not really a viable option for down the road. And what about Neurpo and Parkinsonism.. what are you thoughts on it's efficacy.

Thank you again Dr.Okun

 

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This is not in my opinion an adequate trial of dopamine.  Sinemet needs to be pushed up to 3 tabs per dose in multiple doses before concluding tremor is unresponsive.

Also, the features of PD need to be documented on a scale (UPDRS ideally) as sometimes many other features improve and not tremor.

Some people will also later add dopamine agonists and of course DBS is a great option for tremors that do not respond to meds.

 

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Of course, I don't kknow if he has Parkinson's Disease or Parkinsonism, but I'd like to say, in  hopes that it will provide some reassurance, that I have had Parkinson's (not Parkinsonism) for 10  years, but my very strong tremor never did respond well to Carbidopa/Levodopa. So I'm certainly glad that my MDS did not take that as a sign that I had Parkinsonism, which usually is scarier than PD. C/L seemed to help somewhat with other symptoms, like slowness, energy, & mood, but never did much for the tremor. A couple of  years after diagnosis I  started using a small dose, but within a year I developed dyskinesia/dystonia, and if I took a larger dose, I suffered bad dystonia which made my leg muscles curl up to the point that I could not walk. I had DBS a couple of years ago, which totally got rid of the tremor. Unfortunately, I'm starting to have other problems with DBS, but hope better programming will help. Good luck.

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Thank you Dr Okun

I am confused a bit at this point honestly. My husband tried Neurpro for 4 weeks (4mg) - some to no response according to the Dr. We thought only slight improvment but far more anxiety and agitation and tiredness on it.

Our Dr. is following the scale and he is went from an 8 to 9 between during the 3 month period on Neupro and Azilect.

With the dopamine challengethe Dr took us off the Neupro and suggested that if it is Parkinsonism the Neupro would not be effective.
He also said with Parkinsonism that DBS would also not be an option... is that true?

Do from your comments you feel he should do dopamine at a higher dose for a month, get reevaluated and see if his UPDRS numbers improved. If there is improvement it still could be PD and not Parkinsonism and DBS could still be an option down the road, as would Neupro. 

Would you also suggest he go back on the Neupro and up the dose to 6mg during the dopamine trial?

Thank you again for your input!

Peggy C

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Peggy, it is too complex to know what to do over email but in general I do a levodopa challenge and try to slowly get up to 250-300mg of Sinemet per dose if it can be tolerated and I document the UPDRS scale change.  I would not rule anything out at this point in my view; maybe a 2nd opinion will help you sort this out.

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