The Bad, the Ugly, and the Good of Parkinson treatments: By Maria De Leon

Today, I thought it might be a good time to do some quick review of the PD medications available. As a physician and patient I have can safely say I have tried or been on most medications if not all. So, I will give you my unbiased opinion of my experience as patient and doctor of each medicine. This in hopes of helping you make informed decision about your treatment options as well as recognizing any possible side effects related to them.

Here it goes:
Although, Sinemet is by far one of the oldest and still considered gold standard in treatment of PD, I will discuss last.

First, I will tackle dopamine agonists- which were the first to come out on the market as a novel treatment back in the mid 19190’s binding the dopamine receptors at various locations with greater affinity at some spots than others hence for the differences in each.

Mirapex was the first of this class. It is now available in regular and extended form. i believe this is a great drug and works well for all Pd symptoms and can be used long term with little consequences in most people. However, over time it may loose its affinity (>5 years) but can be reintroduce after a short withdrawal period of about 6 months and have initial full effect. The biggest problem I and my patients experienced with this medication is profound sedation. For most this resolves within a week to two. in others such as myself it can be persistent with best practice recommendation is to find an alternative treatment. In my practice, since this was one of the few choices at the time, I often used in combination with provigil or nuvigil to decrease sedation and improve function. Danger is severe sedation impairing driving which was my problem. Mirapex ER compound in my experience is equally sedating plus at least in me and other people I know caused a dry cough ( akin to bronchitis which also made breathing difficult) that lasted up to a couple hours. this appeared to occur about an hour after intake. The other problem most people worry about is increased sexual drive and OCD behaviors. in my experience, the sexual drive wanes a after a couple of weeks usually and is more common in men than women. as far as the punding and gambling and other aberrant behaviors usually occur after long term treatment with monotherapy. I treated over a thousand PD patients and to this day i am not aware of this issue in any of my patients but all my patients took a cocktail of various medications at lower doses.

Requip regular and extended caused same type of sleepiness and often caused mild visual hallucinations even in young people with no signs of cognitive function.

Neupro 24 hour patch because of its delivery system it provides a constant release of dopamine agonist thus much better equipped at controlling and preventing motor fluctuations. This medication is easily titrated like mirapex to desired dose. Skin irritation is a major component especially as you graduate to larger patches (i.e. higher dose). For most people maintaining a good rotation to avoid same spot for 3 -4 days at least greatly improves this contact dermatitis. Sometimes the use of topical benadryl or cortisone after removal of patch helps decrease the sensitivity. However, if a painful rash develops or not reseeding it must be stopped. One of the biggest differences between this and other two is the initial surge of energy -given you a high like when on steroids or adrenaline rush. thus may keep you up for a couple of nights. this effects usually lasts only a few days. i personally welcomed this effect since it allowed me to do many things. effect simply wears off without causing a crash in the system. thus, unlike the other 2 dopamine agonist, this one does not cause daytime sleepiness. Plus because it bypasses the gut does not cause nausea. although nausea is not a huge component of dopamine agonists in general. All agonists, in particular larger doses of neupro cause increased swelling / fluid retention especially in women and hence increase blood pressure- an important factor to remember. I treat with a mild diruetic which helps decrease fluid and prevent my blood pressure from going up. Interestingly, in my experience, I have seen the opposite effect in men, no real fluid retention but also a propensity to drop Blood pressure thus more prone to have orthostatic hypotensive episodes particularly with higher dosage of neupro patch. again, sometime to watch out for especially if thin and on blood pressure medications or other medicines that cause low blood pressure.