GENERAL PRINCIPLES
- Motor symptoms are treated by replacing dopamine. Like the oil can helping the Tin Man in The Wizard of Oz, dopamine helps make movements quicker and more fluid.
- Medications improve daily symptoms but do not slow the progression of disease over time.
- Medications are taken daily on a routine schedule to control symptoms.
- Nausea is the most common side effect of dopamine therapy.
- PD meds should NOT be stopped abruptly, as doing so can cause a life-threatening condition. Please consult with your provider on how to properly wean off a medication if it becomes necessary.
- Non-motor symptoms typically do not respond to dopamine and require other treatment strategies.
KEY DEFINITIONS
ON time
- Times when the medications are working well, and PD motor symptoms are well-controlled
OFF time
- Times when the medications are not working, and the PD motor symptoms are poorly controlled
Wearing OFF
- Medication loses its effect before the next dose is due, resulting in an OFF time
Unpredictable OFF
- Occurs randomly and is not related to timing of the dose of medication
Morning OFF
- Severe OFF symptoms are present upon waking, due to an extended time since last dose, and before the morning dose takes effect
Dose failure
- When a dose is taken and does not provide control of movement symptoms, usually due to gastrointestinal issues
Dyskinesia
- An abnormal, excessive, involuntary movement caused by PD medication
- Squirmy, wiggling, or even dance-like movements that can occur anywhere in the body
MAINTINENCE MEDICATION
Levodopa
- This is the most potent medication for controlling PD motor symptoms.
- Levodopa goes into the brain and becomes dopamine.
- Levodopa must be given with carbidopa, which blocks the breakdown of levodopa in the body and allows it to cross the blood-brain barrier and be converted to dopamine.
- There are various forms of carbidopa/levodopa:
- Sinemet
- Sinemet CR
- Stalevo
- Rytary
- The effect of the dose typically lasts 4-6 hours.
- The medication is taken three times during the most active part of the day.
- If wearing off occurs, the frequency is increased, or a levodopa-extending drug is prescribed.
Levodopa extenders
- These medications block the breakdown of dopamine in the brain, allowing the levodopa to last longer and help prevent wearing off.
- Classes
- COMT inhibitors
- Entacapone
- Opicapone
- MAO inhibitors
- Selegiline
- Rasagiline
- COMT inhibitors
Dopamine agonists
- These medications mimic the activity of dopamine but are not as potent as levodopa.
- They can be used initially for treatment or in combination with levodopa.
- Dopamine agonists are:
- Pramipexole
- Ropinirole
- Rotigotine patch
- Rare but serious side effects include:
- Impulse control disorder
- Sleep attacks
- Dopamine agonists are used with caution in the elderly because of potential for additional side effects, such as:
- Confusion
- Memory loss
- Hallucinations
MEDICATIONS FOR SPECIAL CIRCUMSTANCES
Rescue medications
- These are on-demand therapies used to treat wearing off, unpredictable off, and early morning off episodes.
- The effects typically take 15-20 minutes to kick in and usually last about 90 minutes.
- Rescue medications are only taken as needed.
- Rescue medications are:
- Apomorphine injectable and sublingual film
- Side effects include nausea and drops in blood pressure.
- Levodopa inhaler
- Side effects are the same as levodopa tablets, plus cough due to inhaling a very fine powder.
- Apomorphine injectable and sublingual film
Medications for dyskinesia
- Abnormal, excessive involuntary movements are caused by the PD medications.
- Dyskinesia medications are
- Gocovri
- Amantadine
- These medications may cause hallucinations.

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