Windsor Parkinson Meeting April 22, 2014

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Cut- A - Thon For Parkinson's Sunday April 27, 2014

Parkinson Society Southwestern Ontario.png Parkinson SW rgb EN.jpg

Parkinson home.jpg . . Welcomes Guest Speaker : Mr. Peter Dumo, a Pharmacist with Nova Care Pharmacy

"is also President of the Essex County Pharmacist Association."

Parkinson's Support Group

Medications for people living with Parkinson’s Disease

General Principles

  • treafinent is individualized
  • focus is on quality of life, benefit risk

Dopamine Agonists (pramipexole. ropinirole )

  • often used first line because less movement disorders than levodopa-based treatments
  • may not be as effective but better benefit risk ratio
  • preferred in younger patients
  • dosed three times daily, slowly titrated
  • most common side effects: swelling, sleepiness (sudden dramatic), constipation, dizziness, hallucinations, and nausea
  • impulse control disorder


  • most effective treatment, especially for severe rigidity or "frozen" patients * always combined with carbidopa or benserazide to allow brain lievels (Sinemet or Prolopa) to prevent nausea, dizziness, and vomiting
  • common approach is to start low and gradually titrate up - then switch to slow release version
  • nausea common with initial low doses because of low amounts of carbidopa
  • initially take with a snack, but with advanced disease empty stomach may better for absorption
  • common early side effects: Nausea, somnolence, dizziness, and headache
  • more advanced disease/elderly: confusion, hallucinations, delusions, agitation, and psychosis
  • prolonged use = movement disorders (dyskinesia, dystonias and complex motor fluctuations) develop
  • wearing-off phenomenon also happens

Selegiline and Rasagiline

  • modest effect, especially in early disease (? neuroprotective)
  • selegiline dosed once or twice (AM and Lunch) whereas Rasagiline dosed once daily
  • do not combine with certain antidepressants, pain medicines without close MD supervision


  • only works in combination with Levodopa
  • added to deal with "weaning-off phenomenon, provides more "on-time" boost Levodopa effect
  • patients often need a DECREASE in Levodopa dose
  • side effects related to increase Levodopa effect plus orange discoloration of urine and rare diarrhea

Benztropine and trihexyphenidyl

  • useful in < 70 with significant tremor or those with advanced disease despite max Levodopa
  • causes confusion and hallucinations (more so in the elderly)
  • dry mouth, blurry vision, difficulty urinating and prostate problems

<--Page_2  Timing of Medications

  • Timing matters, especially with levodopa-based treatment
  • cleared quickly from the body so missed doses or delayed doses can cause severe worsening
  • stopping dopamine-based drug can precipitate severe rigidity (Parkinsonism-Hyperpyrexiui )
  • seligiline and rasagiline should be taken in the AM (less insomnia)

Side effect management


  • look at medication(s) that may cause (benztropine)
  • may be due to dysautonomia, decreased walking around nutritional intake
  • optimize fluid and fiber intake
  • may add PEG powder, then stool softener, then laxative, then suppository then enema
  • 1-2 week between each stage
  • increasing Levodopa may help


  • typically occurs late in the course of PD, may be related to "Lewey Bodies “, different than AD
  • Rivastigamine and Donezipil have been found helpful in PD -Dementia
  • discontinue amantadine and benztropine if possible

Sleep Disturbance

  • difficulty turning over, nocturnia, neck/back pain, restless legs, wild dreams, tremor
  • Restless legs - adjust dopaminergics, add opioids
  • Hallucinations/Psychosis - adjust Levodopa, add Seroquel or Clozaril
  • Nocturia - OAB medications
  • RBD - Rapid-Eye Movement Behavior Disorder- Clonazepam melatonin

Daytime Sleepiness

  • Sleep Hygiene, address depression, review medications
  • adjust dopaminergics and add modafinil

Urinary Disorders

  • related to disease progression, general aging or PD_drugs
  • need proper diagnosis to determine best treatment – usually anticholinergics

Swelling usually due to dopamingeric agents, responds to dose decrease or stopping using diuretics may help, but may contribute to other problems (falls, urinary issues, constipation )

Some information links below.
Meeting Followup

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Use Rick's online contact form HERE.

Windsor Parkinson’s Support Group

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