Parkinson’s disease: Management-a quick one on one

In this blog post let us dwell on the management of Parkinson’s disease (PD). As stated earlier PD is a progressive neurodegenerative disease. This means that as of now PD CANNOT be cured. Once the disease begins it slowly but surely progresses. The rate of progression varies from patient to patient. While PD cannot be cured, there are a number of medications available which can control the symptoms of PD. At times the response with these medications is dramatic and very gratifying. A few salient points:

NOT every patient of PD needs to be treated. When PD initially begins the symptoms are usually mild and may cause minimal interference to the patient’s lifestyle. The mild tremor of PD might be dismissed by the patient as a mere nuisance. At this stage of the disease, the patient does not exhibit problems with his/her gait or balance. The rigidity, bradykinesia is not disabling. At this stage of the disease, the neurologist may opt to simply keep the patient under observation. The patient and the family are educated about the disease and instructed to remain in follow up (come for follow up appointments after very 3-4 months).

The most effective medication for the treatment of PD is LEVODOPA. Since PD is caused by deficiency of dopamine in the brain, the most effective way to treat it is to give dopamine from outside. So levodopa is administered in tablet form usually 3 times a day. Levodopa is combined with another chemical called carbidopa which helps to prevent the breakdown of levodopa in the stomach and thus ensures that high level of levodopa is absorbed and reaches the brain. This combination of LEVODOPA+CARBIDOPA is the main medication used to treat PD. LEVODOPA+CARBIDOPA combination tab is marketed by many different pharmaceutical companies under different names (Please check the common brand name of this combination in your country). The tablet is usually started at low dose three times a day. The neurologist then titrates the dose up based on clinical response and side-effects. The medication is usually well tolerated by most patients and the effect is gratifying. It is important to emphasize that this medication still remains the MOST effective medication for PD. LEVODOPA comes in many different formulations including now in an inhaled form. These formulations are prescribed as the disease advances. Please discuss the same with your neurologist.

DOPAMINE AGONISTS: is another class of medication commonly used to treat PD. As the name suggests medications in this class act by stimulating dopamine receptors in the brain. While not as effective as LEVODOPA+CARBIDOPA, dopamine agonists are commonly prescribed. Commonly used dopamine agonists include pramipexole (Mirapex), rotigotine (Neupro), and ropinirole (Requip). Some neurologists prefer to use a medication in this class as first line treatment and use LEVODOPA+CARBIDOPA when PD symptoms are more bothersome (PD is more advanced).

Amantadine is another medication used to treat PD. It is usually used in combination with either LEVODOPA+CARBIDOPA or DOPAMINE AGONISTS.

Anticholinergic drugs such as benztropine and trihexyphenidyl are also commonly used. These drugs are helpful in controlling symptoms such as tremor and muscle stiffness.

Drugs referred to as selective MAO B inhibitors such as selegiline are used by neurologists usually early in the disease course. There is limited evidence to suggest that medications in this class may be “neuroprotective”.

COMT inhibitors: another class of medications used in the treatment of PD.

Neurostimulator such as DEEP BRAIN STIMULATOR (DBS): A neurostimulator called DBS is sometimes implanted in PD patients. DBS is usually implanted in the brain of PD patients with advanced disease who are experiencing motor fluctuations, medication side-effects called dyskinesias and medication refractory tremor. Please discuss this further with your neurologist.

While medications form the cornerstone of treatment of PD, there are a number of other simple interventions which are very effective. It is important to remember that PD affects the motor system causing problems with gait and balance. Hence I make it a point to emphasize the importance of exercise to my patients and their family. Exercises which improve gait and balance are the most helpful.

dance is a good exercise for patients with PD. (USEFUL RESOURCE: https://danceforparkinsons.org/)

–many are surprised to find out that boxing is a good exercise for patients with PD (USEFUL RESOURCES: https://www.rocksteadyboxing.org/ and https://www.youtube.com/watch?v=XC1h4ygl878)

–yoga is also a good form of exercise-it improves balance and helps reduce the stiffness in PD patients)

Parkinson’s disease patients are prone to falling. Hence falls are an important cause of morbidity in patients with PD. So simple interventions designed to reduce the risk of falling are helpful. (USEFUL RESOURCE: NATIONAL INSTITUTE ON AGING: Fall proofing your home https://www.nia.nih.gov/health/fall-proofing-your-home#:~:text=Keep%20electric%20cords%20and%20telephone,your%20way%20when%20you%20walk.)

Nitin K Sethi, MD, MBBS, FAAN

Director and Chief Coordinator Brain Care Foundation (https://braincarefoundation.com/)

Please support ongoing research in PD and more importantly PD patients and their families. Source of image is http://www.outsourcestrategies.com)

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