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Withdrawal severity scale

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Could you please share your experience.

I was prescribed a dopaminergic drug as an adjunct. But there is an option.

1. Selegiline
2. Amantadine.
3. Cabergoline.

As I understand all these drugs have different mechanism of action - dopamine receptor agonism (cabergoline), increasing dopamine release/dopamine reuptake inhibition(amantadine), MAO inhibition that causes dopamine level increase (selegiline).

Could you evaluate frequency and severity of withdrawal syndrome? Which of the drugs has more likely and more severe withdrawal syndrome? And vice versa - less likely and less severe? I mean severe withdrawal syndrome like DAWS.

My diagnosis is psychiatric, not Parkinson.

Thank you.

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And one more question regarding Selegiline.

Are food restrictions required really for 5mg dosage? Is there real danger of cheese effect?

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from https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/019334s019s020lbl.pdf


In theory, since MAO-A of the gut is not inhibited, patients treated with selegiline at a dose of 10 mg a day should be able to take medications containing pharmacologically active amines and consume tyramine-containing foods without risk of uncontrolled hypertension. Although rare, a few reports of hypertensive reactions have occurred in patients receiving Eldepryl at the recommended dose, with tyramine-containing foods.The pathophysiology of the ‘cheese reaction’ is complicated and, in addition to its ability to inhibit MAO-B selectively, selegiline’s relative freedom from this reaction has been attributed to an ability to prevent tyramine and other indirect acting sympathomimetics from displacing norepinephrine from adrenergic neurons. However, until the pathophysiology of the cheese reaction is more completely understood, it seems prudent to assume that selegiline can ordinarily only be used safely without dietary restrictions at doses where it presumably selectively inhibits MAO-B (e.g., 10 mg/day).

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Thanks for the questions and hopefully I can clarify this for you.

The DAWS is primarily used for Dopamine Agonist medications. So, Right away we are left with one, which is Cabergoline. Now this was just approved for use in Parkinson's in the UK, but has been used worldwide for many years to control prolactin relief. From my experience, it has not beed used in the treatment of Parkinson's disease due to it's high affinity for he d2 receptor, which has little affect on the relief of Parkinson's patients. Most, if not all, of the Dopamine Agonist medications used for Parkinson's have a high affinity for the d3 receptor, which is the primary receptor for Parkinson's disease. It is for this reason that the Dopamine agonist medications are used in the DAWS system, not Cabergoline. Since the withdraw issue is primarily used for Dopamine agonists that have the high affinity for d3.

In saying that, the theory of "start low and go slow" is primarily talking about Dopamine Agonists, but I also use it for any Parkinson medication. Start at the lowest possible dose and increase the strength or frequency slowly to avoid any possible adverse affects.

Amantadine is classified as an antiviral medication and would not fall into the DAWS. It is usually prescribed at 100mg one to two times daily with a max dose of 200mg daily. A new long acting amantadine has come to market called Gocovri. It is a once a day, controlled release formula of amantadine.

Lastly Selegiline, which also does not fall into the DAWS category.  Selegiline is a very old medication, that was used for Parkinson's, but has basically been replaced by a product called Rasagiline (brand name Azilect.) Selegiline dosing schedule was very difficult, the interaction with food products was/is real and can be dangerous, and one of the by products is an amphetamine like product. The dosing was difficult due to the amphetamine like metabolite. It could not be dosed any later than 6:00pm due to the metabolite causing patients to stay awake. The foods to avoid were those that contained Tyramine, such as aged or cured meats, aged cheese, different wines, draft beer, sauerkraut, soy beans, soy sauce, tofu, and a few others. The reaction can a severe spike in blood pressure and result in an emergency room trip.The new product, Azilect (Rasagiline), is what we call a very distant cousin to selegiline. Newer products are developed from older medication to either decrease the amount of medication needed to relieve the symptoms, to decrease the strength of the medication, or to eliminate some of the major side effects. The warnings on Rasagaline hint that there may be a food interaction, but there has not been one documented. In my more than 25 years of experience, thousands of patients I have spoken with, and hundreds of doctors I have consulted with, none of them have had the tyramine reaction with Rasagiline.

I hope this helps and please keep me posted.

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