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Cheaper, Simpler and Better: Tips for Treating Seniors With Parkinson’s Disease

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Dr. J. Eric Ahlskog, a Consultant in the Department of Neurology at Mayo Clinic in Rochester, MN, discusses his article appearing in the December 2011 issue of Mayo Clinic Proceedings on the effectiveness of treating Parkinson’s Disease with carbidopa/levodopa and notes its most effective dosage regimen is tailored to the needs of the patient. Available at:

Hello i’m dr. eric all skog from the department of neurology at the mayo clinic in rochester the section of movement disorders and i was invited to tell you about a few of the high points from the paper that is coming out in the december issue of the mayo clinic proceedings entitled cheaper simpler and better tips for treating seniors with parkinson’s disease so

This is a subject near and dear to my heart i see a lot of folks with parkinson’s disease i’ve been seeing them in trying to help them over the past thirty years and there are a few basic principles that i thought are absolutely crucial in treating them and moreover i thought that the treatment really should not be confined to neurologist but treatment of seniors

With parkinson’s disease is something that really ought to be in the domain of primary care physicians and internist and that’s where i would like to see it golf more and more so this is bread and butter medicine parkinson’s disease is common this is not a rare disorder by one estimate there are about 1 million people with parkinson’s disease in the united states

Very common very treatable now we do not have any medications that get at the cause of parkinson’s disease some have been advocated but really what we’re doing is treating the symptoms and vehicle back to the basic clinical trials on parkinson’s disease treatment we are treating the symptoms so what’s the best medicine for treating the symptoms well it’s a medicine

That’s about four years old it’s carbidopa levodopa and there have been a number of competitors that are appropriate in certain situations but if you’re talking about seniors if you know carbidopa levodopa and are good at using that you can change a lot of lives for the better among people with parkinson’s disease the people with parkinson’s disease have a dopamine

Deficiency and this is what we are trying to replenish with levodopa therapy so obviously levodopa is the precursor to dopamine this is by far the most efficacious way that we can replenish brain dopamine now in the past 20 years or so there have been quite a few papers written about how we should defer levodopa we should keep the doses low and this conservative

Treatment i think is doing a lot more harm than good if you don’t use it you’ll lose and i think that’s what we’ve done to a generation of people with parkinson’s disease we have been collectively very conservative in using levodopa therapy and so we’ve relegated the generation of parkinson’s disease patients to the couch watching tv not going out not exercising

And there is now an emerging literature suggesting that exercise does a lot of good things to the brain and we should not be depriving folks with parkinson’s disease with the best treatment and trying to withhold it for some future date for reasons that really have not been proven so let’s start from that premise we have the best medicine out there carbidopa levodopa

How should we use it well it turns out the simplest way to use it is with the old-fashioned 25/100 carbidopa levodopa tablets the regular formulation not the controlled release the regular formulation using the 25100 formulation that’s 25 milligrams of carbidopa 100 milligrams of levodopa and i’ll tell you my strategy for initiating that it’s a single 25100 tablet

An hour before each of three meals why an hour because levodopa is a large neutral amino acid when you consume proteins which is our meals the proteins are digested into the constituent large neutral amino acids and they compete with levodopa at the blood-brain barrier where there is an active transport mechanism that is easily saturated with dietary amino acids

So you need to take carbidopa levodopa on an empty stomach and really to be certain that you’re doing it properly tell your patients to take it at least an hour before meals so you start out with one tablet three times a day typically that’s too low to do a lot of good so i have a schedule one tablet three times a day the next week one week later one and a half

Tablets three times a day then two tablets three times a day then two and a half tablets three times a day and clearly the point of diminishing returns for people with parkinson’s disease is two and a half and at the most three tablets at a time or three tablets three times a day so i have never seen people in my practice who say i did better on four tablets or

Five tablets or six tablets provided as the immediate release formulation taken on an empty stomach so that’s an important thing to know now you can always go backwards so they come back to see you in six weeks and they say you know i was doing just as well on two tablets three times today is two and a half or three can always go backwards and then that’s their

Maintenance dose and then that’s what you maintain what’s the target you’re trying to achieve keeping people ambulatory and active and fully engaged in their lives now the couple satellites here that are worthwhile i’m mentioning so the issue always comes up what about dyskinesias what about wearing off effects well those are not things that start early in the

Course of parkinson’s disease these start to surface after some years and so this reflects an unstable levodopa response so this is a little bit like a type 1 diabetic getting insulin so insulin typically early on diabetics has a very stable response you can get the blood sugar targeted to where you need it and pretty easy to treat type 1 diabetes after a number

Of years there is a percentage of people have become brittle diabetics where you can’t stabilize some blood sugar and so this parallels what happens in parkinson’s disease and in parkinson’s disease if you live long enough and have it long enough typically the responses start to take on this short duration type of pattern so early on the responses are long-standing

So it’s a an effect that builds up over about a week’s time on a given dose after several years more of the response gets tied to the dose you just took and these are the short duration responses remarkable or responsible for fluctuations these are the same responses also that are linked to involuntary movements korea form movements dyskinesia and so dyskinesias

Reflect too good of an effect so what do you do about short duration responses you use the dose that works the best and your shorten the interval between doses to match the response duration you don’t worry about number of doses or tablets per day and whatever that person needs you give them sometimes they need this at night to cover sleep insomnia is common among

People with parkinson’s disease and if it’s not insomnia they they had all their lives then they simply need a full dose of carbidopa levodopa perhaps at bedtime and perhaps again during the night so what do you do about people that come back to see the clinician and now they’ve got a lot of wigleigh movies well those are the dyskinesias those are the korea form

Movements in korea form movements reflect an overdose effect now it’s not dangerous but obviously you want to get rid of those if you can and they relate to the dose that person just took so dyskinesia is occurring now have nothing to do with the dose you took yesterday or even eight hours before so what do you do about that well you lower each dose so people come

Back to see the clinician they say i have a lot of dyskinesias and you see those and they’re on two and a half tablets each dose then you reduce the dose from two and a half down to two if that isn’t enough then they can go down from two to one and a half and excuse me and so on and now what’s happened sometimes is as you lower the dose then the parkinsonism is

Not as well controlled and that may happen then you have a decision to make is this which is more troublesome the dyskinesias or the parkinsonism and that’s sometimes that can be a problem but the patient can be a party to the decision so there you have it carbidopa levodopa do you need all kinds of other drugs do you need mirror pecs and requip and compton and

A select solidly and efrain element you know i say let’s keep things simple stick with the old best drug carbidopa levodopa and you all have a very gratifying parkinson’s disease practice the best of luck in treating your parkinson’s disease community thank you we hope you’ve benefited from this presentation based on the content of mayo clinic proceedings her

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Cheaper, Simpler and Better: Tips for Treating Seniors With Parkinson's Disease By Mayo Proceedings