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YD2018

From SInemet with Mirapex to Sinemet with Neupro

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Dear Doctor Okun!

I am 65. Work full time. Diagnosed with Parkinson’s in 2012.  Up till August 2018 was treated with Sinemet / 2 tablets 100/25 X 5 times a day – every 3 hours (7 AM to 7 PM) and Mirapex (1 mg tablet X 3 times a day). While my Sinemet dose has been increased slowly, my  Mirapex dose has not been changed since 2015. It was never perfect. But I functioned some-how till summer 2018, when my condition worsened. I lost my sleep. My stomach was irritated.  I would sleep 2 hours max at night; was mostly restless at night. During the day I was very tired, my tremors got worse.The single dose of medication would wear off in about 2 hours – did not last for 3 hours.  

My neurologist suggested to try Neupro/Rotigotine – 24 hours patch. We started one month ago.

I had to take some time off the work as it did not go as fast and smooth as we hopped!

 I withdraw from Mirapex (very slow  -  as I experienced withdrawal effect when tried to go faster initially) and gradually increased the Neupro dose – 2 Mg - first week – 4 Mg - second week, –6 Mg - ...  -  8 Mg ...

I tried 8 mg Neupro/24hr patch for a few days but felt that the dose is too strong for me. - felt it was overstimulating my brain.

 

At this point in time is around 1.5 week as I am on Neupro 6 Mg/24h patch and 2 tabs of Sinemet 100/25 X 5 times a day – every 3 hours (7 AM to 7 PM).

Sleeping got bit better / 4 – 5 hours at night. My stomach has calmed down.

But the following feels worse. At night, the new medication seems having too strong drowsy effect on me. It is very hard to wake-up as needed to go to bath room at night; very difficult to move in bed, stand up from the bed and walk at night and in the morning - my wife helps me.

I did not need my wife 's help at night before when using Mirapex.

The balance and moving/walking at night /morning is very poor and laborious. In the morning, I have to take Sinemet right after wake up - only after that I can dress, brush my teeth, walk down the stairs, etc ... I could dress slowly and go down the stairs prior to taking any Sinemet in the morning prior to my medication change.

During the day - I feel that  I am under-medicated overall. My Sinemet dose wares off in  about 2.5 hours. My balance, walking is worse, my endurance and energy decreased compare to my "best days" back in May - June 2018/ To be fair, I had some worse days with the Mirapex also

Currently when waiting for Sinemet to go “ON”, my neck, shoulders, legs, arms become very stiff; hands intensively shaking . Usually it takes 30 min or less for Sinemet to get “ON” . Shaking stops. Muscles relax.

I often feel a bit drowsy during the day time also. If I take a nap or fall asleep during the day - waking up takes long time and for  the following dose of Sinemet to get ON - would need to wait twice as long as usual - up to 1 hour.

 I am sill off work. Would love to go back to work when my condition improves

 I  read your book:

 Dr. Michael Okun: “Parkinson's Treatment: 10 Secrets to a Happier Life”.

 Tried to think on how to apply some of “the secretes” to my case.  

Questions :

 

I was thinking that I may be able to tune the Sinemet time/dose to optimize the overall medication action. 

I could try to keep the dose of 2 tabs of Sinemet but apply it more often - every 2.5 hours (instead of 3 hours) starting at 7 am and continue to 10 PM when I go to sleep.

1) Is this the right approach to try in my case ?  What do you think ?

2) What could you recommend to try to optimize my Sinemet with Neupro medication?

3) What else would you recommend to try at this point?

4) Could it be that Mirapex ( 1 mg X 3 times daily) was providing a stronger support compare to Neupro 6 Mg/24h patch  at the day time ?

 

 

 Thank you and best regards!

Edited by YD2018
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This is a tricky case, and I will give a shot to few answers:

I could try to keep the dose of 2 tabs of Sinemet but apply it more often - every 2.5 hours (instead of 3 hours) starting at 7 am and continue to 10 PM when I go to sleep.

--Sometimes if you are wearing off between dosages this may help.

1) Is this the right approach to try in my case ?  What do you think ?

-There is no one right approach; you and your doc will need some trial and error.  It is possible that Mirapex just simply works better for you and you could consider that in your decision making.  Of course weaning agonists should be slow to avoid withdrawal and some people exposed to agonists have a hard time substituting Sinemet.

2) What could you recommend to try to optimize my Sinemet with Neupro medication?

-I think you are on the right track but you may ask your doc about lowering the Neupro so you are not sleepy and looking at med intervals and doses of Sinemet.

3) What else would you recommend to try at this point?

-You could go back to Mirapex, try a Duopa pump or consider DBS.

4) Could it be that Mirapex ( 1 mg X 3 times daily) was providing a stronger support compare to Neupro 6 Mg/24h patch  at the day time ?

-Yes

-Hope that helps and good luck.

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Thank you Doctor Okun!

My  doctor would like me to re-try the Neupro 8 mg patch. He thinks that we may previously went from 6 mg to 8 mg too fast.

After being on 6 mg patch for 2 wk, I re-tried using the 8 mg patch once more. Surprisingly it went easier than the first time and I think that I feel less drowsy ..

It has been used 3 days; plan to try the 8 mg patch for few more weeks to see the results.

At the time of our meeting, my doctor was not sure on exact relation between the Mirapex and Neupro / Rotigotine in milligrams.

According to the following URL link , 1 mg of  Mirapex is equivalent to 4 mg  of Rotigotine :

https://www.researchgate.net/figure/Approximate-dose-equivalents-for-pramipexole-ropinirole-and-rotigotine_tbl5_51462604

 

Question:

Based on the 1 to 4 ratio above,  my old dose of Mirapex 1 mg tablet 3 times a day is approximately equivalent to 12 mg Neupro/Rotigotine  24 Hr patch !

Do you think this is the correct conversion?

 

Thank you & best regards!

Edited by YD2018
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I don't buy into all the formulas as being exact.  I follow symptoms.  Reasonable to use formula and go slow, but titrate up or down by symptoms as it is just a guess.

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