Dr. J. Eric Ahlskog, a Neurologist specializing in Parkinson Disease at Mayo Clinic in Rochester, MN, breaks misconceptions regarding treatment for Parkinson disease in his article appearing in the October 2020 issue of Mayo Clinic Proceedings. He looks at the most efficacious drugs, the detrimental side effects of newer drugs, and covers best practices for dosage and times for medications, noting that taking Levodopa with food limits its effectiveness, that sleep disturbances can be managed by maintaining medication levels, that evidence supports starting Levodopa as soon as Parkinson disease is diagnosed, and that primary care physicians should readily be capable of treating their patients with Parkinson disease. Available at:
Quite frankly we have a shortage of doctors in north america that can treat parkinson’s disease as i learned from patients that see me there is often a several month wait for somebody with newly diagnosed or newly recognized parkinson’s symptoms to get an appointment with a neurologist hello permit me to introduce myself i am eric alsgog mayo clinic department
Of neurology and i am here going to talk about this paper that is being published in the mayo clinic proceedings entitled common myths and misconceptions that side track parkinson’s disease treatment to the detriment of patients and this is something that i have thought is a very timely kind of monograph to discuss an issue that i is near and dear to my heart
I have long argued that parkinson’s disease should be managed at least initially by primary care clinicians and that is something that is very doable unfortunately we’ve made it so complex we being the intelligentsia of the parkinson’s disease community we have made it so complex that a lot of primary care physicians just really can’t take on cannot take on
That endeavor why is it so complex well there are multiple medications number one number two there are a lot of misconceptions and that’s what the purpose of this paper is to address the misconceptions and fictions that have surfaced over the course of the last 30 or 40 years that relate to the management of parkinson’s disease so one of the myths that’s that i
Have included in that article is levodopa stops working after a couple of years i’ve seen that in print and i’ve had patients tell me that what what is that all about well it doesn’t after 10 15 years it doesn’t work as well it still works and you don’t see people that when they get to be age 75 or 80 they stop taking levodopa they still need it and they still
Get a beneficial response but it’s not as complete as it was early on so there’s one fiction that i think we can put aside here levodopa only works for two years or a few years no it works for many years but you do have to adjust the dose and you have to optimize the dose here’s another fiction save liga dopa for later it used to be thought 20 years ago back in
The 1980s 1990s that dopamine was the cause of parkinson’s disease and we now know that that’s silly because it isn’t just dopamine circuits and some dopamine circuits are spared and some dopamine circuits even within the niagara estradal system are spared so this is not a dopamine substrate that causes parkinson’s disease but that still has lingered on as we’ve
Taught residents and young doctors that well we should save levodopa and when you use it don’t use very much here’s another fiction give levodopa with food why is that well to prevent nausea well the point of fact with the carbidopa added to levodopa carbidopalibidopa the brand name for that years ago was cinnamon cinnamon is latin for cine without emesis without
Nausea now in point of fact if you give leave a double with meals it doesn’t go to where you want it to go to the brain and the problem of course is is that that dopamine transporter that transports levodopa to the across the blood-brain barrier into the brain that levodopa transported there it’s an amino acid transporter is easily saturated with dietary amino
Acids so what you need to do is take the levodopa separately from meals so what are the rules that you can tell your patients to make certain that each dose of levodopa will optimally kick in among people that have these wearing off responses they can tell you exactly how long before a meal they need to take their dose of carbidopa levodopa and what i have
Learned is that you’ve got to take it at least one hour before meals what about after the meals well if you think about it eat a meal eat the hamburger you liberate all those hamburger protein derived amino acids into the bloodstream and what happens is they’re circulating there for a while well how long do they circulate well those same patients have taught
Me that to guarantee that their dose of levodopa is going to work it needs to be taken at least two hours after the end of a meal other misconception about treating parkinson’s disease a lot of folks with parkinson’s disease have insomnia trouble getting to sleep trouble staying asleep and i can remember reading years ago when i was newly on staff there was a
Paper published saying that you don’t want to give levodopa close to bedtime because it changes the architecture of sleep well in point of fact if you have parkinson’s disease and you’re in a levodopa untreated state or a levodopa off state you cannot get comfortable in bed so what i tell people is early on when you have these around-the-clock effects if you
Take the three doses during the waking day typically those carry throughout the night and people sleep well but people that have this wearing off of the levodopa effect quite often what happens is if their last dose is let’s say before supper time and then they go to they go to bed at 10 30 or 11 the levodopa effect is played out can’t get comfortable so you
Need in those folks with the short duration responses olivia dopa needs to be continued right up to bedtime and in fact if they wake up at three in the morning leave a dope effect is played out then they need another full dose and on tv fifty percent of people with parkinson’s disease develop hallucinations if i’m a parkinson’s disease patient i’m thinking
Man this is this is not good news if i’m a spouse i’m also thinking this is not good news because my husband and wife are going to start hallucinating what am i going to do then well in my experience hallucinations and just pure parkinson’s disease and i’m not talking about lewy body dementia which is a similar but a little bit different disorder but parkinson’s
Disease is not frequently associated with hallucinations in my clinic so when people come to see me and they’re hallucinating the first thing i do is i look at the medicine and as those daring drugs that tend to drive hallucinations so semiob inhibitors azolic and saligiline and it’s a dopamine agonist and the the main drugs that especially drive that would
Be pramipexole which is mirapex rapinroll which is requip to a lesser extent probably the ratigatine which is the nupro patch so those are the drugs that tend to drive hallucinations what i do is look at the medication list with those drugs around there we eliminate those one by one keep an eye on the tolerability of eliminating them and typically you can
Get people off from those and the hallucinations dissipate if people aren’t on any of those drugs i always check of your analysis and i worry about any kind of maybe so you know subclinical infections because those sometimes knock the wheels off the wagon as well that brings us to the dopamine agonist drugs which i have already alluded to and those would be
The the main competitors with levodopa uh for treating parkinson’s disease so the ones that have been in common use over the last probably since the mid to late 1990s would be requip which is repinroll mirapex which is pramipexole those drugs are purported to be as close to as if a cases as levodopa well if you’re a physician in the clinic and you’re trying to
Optimize the treatment of parkinson’s disease they’re not even close to as efficacious as levodopa so you you can’t use those as monotherapy and get people to where you want them also interesting with these dopamine agonist drugs these two particular ones pramipexole and repinerole they have some very interesting side effects the most interesting one of which
Is pathological behaviors that tend to occur in one person and four on therapeutic doses of either ropinroll or pramipexo what are those pathological behaviors well probably the most common one would be pathological gambling in men occasionally women but it’s mainly men pathological sexual kinds of ideation pornography addicts doing very inappropriate sexual
Kinds of things anything that is inherently rewarding can be magnified to pathological proportions if you are on a therapeutic dose of premy pixel or rapinroll and then finally they also have the capacity to induce sleepiness and in fact the initial paper is written about this some 20 years ago described people who are taking pramipexole or repinerole getting
Into car accidents because they were falling asleep at the wheel so this is this is not a class of drugs that i like very much and i’ve actually i prescribed a fair amount of those but i have realized that this is probably not not something that i want to substitute pretty much ever for carbidopa levodopa and finally there’s the issue of what formulation of
Carbidopa levodopa to use and what i’ve been using to keep things simple is the regular old-fashioned 25-100 immediate release carbidopa levodopa and i thank you very much for listening and i hope those of you who are enticed to consider taking on a larger parkinson’s disease practice i applaud you and you’re welcome to send me emails and i’m happy to respond
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Myths and Misconceptions About Parkinson Disease Treatment By Mayo Proceedings