What factors be considered before medication?

I am newly diagnosed with Parkinson’s disease, what factors are considered by my doctor when starting me on a medication?

You ask a very important question. Several factors require consideration when initiating symptomatic drug therapy in Parkinson’s disease. The choice of pharmacotherapy depends on the patient’s age, degree of disability, and cognitive status, as well as the impact of dosing, possible impact on the patient’s employment, domestic responsibilities, and lifestyle. Potential drug side effects must also be considered. Thus there are a lot of factors to consider!

The patient’s age is an important factor in predicting how well certain medications might be tolerated, as the risk of developing dyskinesia and motor fluctuations, especially with levodopa use, increases with earlier/younger onset Parkinson’s disease (most especially those who get it before 50 to 60 years old). Dopamine agonists, which delay the risk of dyskinesia and end-of-dose wearing off, may be offered as a first-line treatment option for younger patients. However, in older patients (which in our field means greater than 70 years old), the dopamine agonists have a higher risk for producing psychiatric and cognitive side effects. In addition, dopamine agonists have a complicated initial titration schedule before a therapeutic dose can be achieved. They require multiple dosing throughout the day, making the use of these agents challenging for many patients but especially so for patients 70 and older, who may be on several therapies for other conditions. Morover, the elderly patient is less likely to develop motor fluctuations and dyskinesias compared to the younger patient. Thus, in the currently published treatment algorithm, it is suggested that for the older patient, levodopa may be a better choice as initial first-line therapy compared to dopamine agonists.

The good news is that recent data suggest that an alternative option for initial monotherapy for early PD patients is rasagiline, a selective monoamine oxidase type B (MAO-B) inhibitor that offers effective control of symptoms and appears to be have a much lower incidence of the dopaminergic side effects seen with dopamine agonists and levodopa.

In one large placebo-controlled, multi-center clinical trial, after 5 years of levodopa use and as Parkinson’s disease progressed, about 50% of patients who were given levodopa from the onset developed motor complications compared to only 20% of patients who were first started on dopamine agonists for their early symptoms. However, the traditional view that treatment of Parkinson’s disease should begin only when symptoms become functionally significant has been challenged by some recent studies suggesting that initiation of treatment at the time of diagnosis results in better clinical outcome later in the course of the disease.

The patient’s perception of their level of disability and its impact on their lifestyle is also a driver of initial choice of therapy. Patients at the early stage whose major presenting symptom is tremor and who have minimal slowness or stiffness may respond to drugs such as anticholinergic agents or amantadine before their symptoms worsen. Rasagiline, selegiline, dopamine agonists or levodopa may be added as the disease progresses.

The potential of therapies to produce untoward side effects based upon the patient age and comorbid conditions is another important factor in choosing initial Parkinson’s disease therapy. As mentioned, dopamine agonists are not a good first choice in older patients due to concerns of leg swelling, cognitive impairment, and hallucinations. In patients in whom excessive sleepiness and drowsiness may affect daily activities, dopamine agonist use may also not be appropriate.

Yours,
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Hubert H. Fernandez
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Anonymous







PostPosted: Tue Nov 17, 2009 8:43 am Post subject: Reply with quote
Good recap ... thanks!

Rich
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Dr. Fernandez



Joined: 20 Jan 2007
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PostPosted: Thu Nov 19, 2009 7:37 pm Post subject: Reply with quote
You are welcome!
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Anonymous







PostPosted: Sat Nov 21, 2009 11:01 am Post subject: Reply with quote
Let me pull out a small portion of your post that is very important - the fact that motor complications occurred more often with the patients on sinemet than on the dopamine agonists after five years.

For those just beginning therapy you must realize that many of these motor complications can be very very minimal. I for example will have movement of my feet first thing in the morning when my sinemet hits my brain. The movement is minimal and causes no problems. No the dopamine agonists did not cause a problem like this but they caused me to faint at least 15 times a day. I did not change because I was afraid to take dopamine.

My point is - don't be afraid to try sinemet (dopamine). It really does work amazingly well (it stopped ALL my PD problems from drooling to freezing to tremor) and the side effects can be controlled one way or another by adjusting dosage and adding or subtracting other things. If the dopamine agonists work for you - GREAT. But if they don't - DON'T WAIT. Get on sinemet. I lost three years of my life because I waited too long to get on dopamine because of the older articles that said that taking it caused the disease to progress faster. From what I understand this is no longer thought to be true.

Good luck all!
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Dr. Fernandez



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Posts: 90


PostPosted: Sat Nov 21, 2009 5:46 pm Post subject: Reply with quote
Thank you for your comments!
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Hubert H. Fernandez