What are the treatment options for Parkinson’s disease?
No single medication can be called the “best” medication for Parkinson’s disease. That being said, for many people, levodopa is a very good anti-parkinsonian medication.
It is useful to know the different treatment options available for managing Parkinson’s disease. You should have a detailed discussion with your doctor about your symptoms, so that the appropriate medication can be prescribed by him/her.
Although in the later stages of Parkinson’s disease Deep Brain Stimulation (DBS) is very useful, it is not required in the early stages. In this article, we will talk only about antiparkinsonian medications. You can read more about DBS here.
Can you show me a list of medications for Parkinson’s disease?
Yes! Knowing the names of Anti-Parkinsonian drugs is a good place to start. There is HUGELY important medication you should know about – It is the biggest animal in the Jungle, the oldest and possibly the wisest – Levodopa
- Levodopa + Carbidopa
There are 4 other very important medications to know.
- Levodopa’s friend: Entacapaone
- The imitators of Dopamine: Pramipexole, Ropinirole
- New medications: Safinamide
These are two other types of medications, with limited role in treating Parkinson’s disease. We will also talk about these briefly:
- Anticholinergics: Benztropine, Trihexyphenidyl
- MAO-B inhibitors: Rasagiline & Selegeline
Let us now talk about each one of these medications in some detail:
Levdopa and Carbidopa
(Brand names: Sinemet, Syndopa, Syndopa plus, Syndopa CR, Tidomet etc)
How does levodopa work?
In a very simple fashion! Levodopa travels inside the brain, and is converted into Dopamine! As described here, low levels of dopamine in the brain is the main problem in Parkinson’s disease. So, levodopa directly addresses the basic problem.
- It is one of the strongest medications for Parkinson’s disease. It has a very marked effect on relieving the movement and many of the non-movement problems associated with Parkinson’s disease.
Disadvantages / Side-effects of levodopa:
- Absorption: Ideally, levodopa should be taken on an empty stomach. You should not eat at least 30 minutes (and if possible one hour) before and after taking levodopa. It is mainly protein in the food that hampers the absorption of levdopa. But, you should drink a glass of water with each dose to help the tablet dissolve.
- Logistics: Levodopa needs to be taken multiple times in a day. In the initial stages it has to be taken 3 times a day, but in the later stages, it may need to be taken 5 or more times per day. It is sometimes difficult to remember to take each dose on time!
- Nasuea: Some patients complain of nausea after taking levodopa. Carbidopa, which is always given with levodopa, does decrease nausea somewhat. If the nausea is so severe that the patient is absolutely not able to take the medication on an empty stomach, then taking levodopa with a small piece of bread can be permitted. It is mainly protein that hampers the absorption of levdopa, and bread does not contain a lot of protein. Sometimes, your doctor may prescribe medications such as domperidone for this problem.
- Lightheadedness: Some people may complain that when they take levodopa, they feel lightheaded especially after getting up suddenly. This feeling usually goes away. Sometimes, it is caused by a drop in blood presssure when standing up. In this case, drinking enough water (7-8 glasses/day if okay with your cardiologist/nephrologist), and getting up gradually helps a lot.
This often is worst in the morning or night – so when you get up from bed at this times, first sit by the side of the bed for some time, then stand up gradually and stand by the side of the bed for some time, and start walking only when you feel perfectly stable (after 30 seconds – 1 minute).
Rarely, medications such as fludrocortisone or Pyridostigmine may need to be given for this problem.
- “Dyskinesias”: Earlier, some doctors used to believe that levodopa should be avoided in very early Parkinson’s disease. The concern was that perhaps the early use of levodopa leads to early development of abnormal movements called dyskinesias. However, most recent research shows that this is not a very strong concern – These movements are now believed to be due to the disease itself, rather than any particular medication. In very young patients, below 45 years of age, it may be reasonable to consider using medications other than levodopa because of this concern.
- Other side-effects: Since this book cannot be comprehensive, it is impossible to cover all side effects here. However, some patients report disturbed sleep etc with levodopa – if you have any of these relatively rare side-effects you should make sure to talk about them with your doctor.
Since it is a very powerful, safe medication with minimal side-effects, levodopa is the most frequently prescribed medication for Parkinson’s disease.
COMT inhibitors: Entacapone
(Brand names in India: Syncapone, Entacom plus)
How does Entacapone act?
Entcapone is a friend of levodopa. It prevents the breakdown of levodopa, and thus makes the levodopa stay longer in the blood. As a a result the effect of levodopa is increased, and more importantly – the effect of levodopa lasts for a longer time.
- It directly increases the effect of levodopa. In some patients, when Parkinson’s disease progresses, the effect of levodopa lasts for a shorter and shorter time. These patients may often say something like the following: Well, I agree that levodopa helps me. It perks me up, makes me want to walk, in fact I can walk very, very well for the first 2 hours after taking levodopa. But, 2 hours later the effect goes away! And I am back to the stage where I was before taking levodopa. This roller-coaster ride continues throughout the day. – This is called “Predictable wearing OFF”. Entacapone is extremely helpful in this situation.
- Rarely, it may cause mild liver side effects. This is not very common.
- The stronger brother – Tolcapone – is not available in India. But Tolcapone can result in serious liver injury and therefore it’s use needs to be very closely monitored.
Who doesn’t need friends? Entacapone is a good buddy of levodopa. It is used when levodopa by itself is not able to produce sustained relief of Parkinson’s symptoms.
- Part 1: Levodopa, Entacapone
- Part 2: Amantadine, Dopmine imitators (Pramipex, Ropinirole)
- Part 3: Anticholinergics, MAO-B inhibitors (Rasagiline, Selegiline)[/su_box
Dr. Kharkar is a Neurologist, Epilepsy specialist & Parkinson’s disease specialist in Mumbai, Maharashtra, India.
He has trained in the best institutions in India, US and UK including KEM hospital in Mumbai, University of California at San Francisco (UCSF), USA & Kings College in London.
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