When it comes to Parkinson’s disease, knowledge is truly power.
According to Dr. Robert Martin, a neurologist and movement disorders specialist at Baystate Neurology, "Over the last decade, there’s been a tremendous amount of research about and drug trials related to Parkinson's disease (PD) that have increased our understanding of the complexity of the disease as well as how best to use different medications to control symptoms and improve quality of life throughout the disease’s progression. That understanding should give patients and their families a tremendous sense of hope about what their future may look like.”
Noting that Parkinson’s disease is a progressive whole-body disease, Martin says at different stages of the disease, patients will require different medications. “Often people think Parkinson’s medications are exclusively intended to address the visible movement disorders—rigidity, tremors, or difficulty walking,” he says. “But the truth is there are numerous other PD symptoms that have an even greater impact on an individual’s quality of life. These are often hidden from view, making PD a bit of an iceberg of a disease. The movement disorders are above the water line where everyone can see them but down below are other symptoms.”
These Parkinson’s disease symptoms may include:
- Loss of sense of smell
- Constipation
- Panic Attacks
- Anxiety
- Pain
- Depression
- Bladder issues
- Hallucinations
- Erectile dysfunction
- Sweating
- Dimension
- Loss of facial expression
- Difficulty swallowing
- Challenges with sleep
- Delusional behavior
- Lack of impulse control
“Over the course of living with the disease for 10 or even 20 years, as many patients do,” says Martin, “Different symptoms may emerge. This means that the medication prescribed to each individual needs to be consistently evaluated and adjusted—sometimes adding a new drug, sometimes stopping one. The good news,” he adds, “is we now have more medication options than ever.”
What Causes Parkinson’s Disease?
Before considering different medications, it’s important to understand what’s at the root of PD.
PD is caused by an issue with cells in the midbrain. Martin explains, “The brain produces different proteins that keep the rest of the body functioning properly. Sometimes the proteins become mis-folded and begin to clump together. The trouble begins when those clumps interfere with cells that produce dopamine, a chemical that regulates movement. As less dopamine is produced, symptoms of PD emerge.”
Medication Options for Parkinson’s Disease
The goal of Parkinson’s medications is to replace the dopamine that’s not being produced and, ideally, to do it in a way that keeps dopamine levels stable.
The most commonly prescribed Parkinson’s medication is Levodopa (L-dopa) as it’s the best current option for controlling the symptoms of the condition, particularly slow movements and stiff, rigid body parts.
Taken by mouth, L-dopa is absorbed by the first part of the small intestine and moves directly into the blood stream. Once it reaches the brain, the brain takes it up and converts it to dopamine. The challenge is taking the medication in a manner that provides a steady stream of L-dopa to convert, thus, keeping symptoms consistently under control.
Today there’s a wide selection of L-dopa formulations including immediate- and controlled-release options plus one drug, Rytary, that offers a combination of immediate- and controlled-release ingredients in one.
Another popular medication option is what’s known as dopamine agonists. These medications include a synthetic/man-made dopamine molecule that works a lot like L-dopa. While patients taking agonist often report less dyskinesia (involuntary movement), there is a higher likelihood of experiencing hallucinations and low blood pressure as well as developing impulse control disorders over the long haul.
Currently dopamine agonists are available in a pill form (Ropinirole and Pramipexole) and as a skin patch (Rotigotine), the latter being ideal for patients experiencing issues with swallowing.
What Medication to Take for Parkinson’s and When
The nice part about having both L-dopa and agonist as options is, well, having options. The challenging part is deciding which medication to take in the course of your disease and when.
When advising patients on medication choices, Martin often cites a study that followed two groups of patients. The first delayed starting taking L-dopa while the second began taking it in the earliest stages of the disease.
The study found that those who delayed taking L-dopa had a lower likelihood of dyskinesia but experienced less impulse control side effects over the long term. The group that started L-dopa early had some dyskinesia, but their quality of life and functional status was better than the other group.
“For those reasons, I encourage the majority of my patients to be on L-dopa early,” says Martin.
Understanding the Role and Value of “Helper Medications”
While L-dopa is considered the gold standard for Parkinson’s treatment, there are other medications that can be taken in conjunction to better control symptoms of PD.
Often described as “helper medications,” the goal of these drugs is to extend the effects of L-dopa in the brain and provide patients with better symptom control, or more good “on” time.
In some cases, patients who use helper medications actually benefit from paring back their L-dopa dosage.
Popular helper options include Amantadine, which treats both tremors and dyskinesia. Martin says, “Amantadine comes in a couple of formulations, including GoCovri, Osmolex, and the generic. All forms, some taken once a day, some twice, provide good tremor control, however, there’s the potential for side effects, most notably, visual hallucinations.”
Another helper drug type Martin often recommends are anticholinergics. He notes, however, that he often reserves these for younger onset PD patients with no signs of cognitive impairment or other comorbidities. Available generically as Benztropine and Trihexyphenidyl, Martin says, “The biggest downside of these medications are the potential side effects including confusion, bloating, and stomach pain.”
New Parkinson’s Medications Offer Hope and Increase “On” Time
In recent years, drug manufacturers have been working to develop drugs to provide PD patients with more good “on” time, which allows them to maintain daily routines and hobbies. Three of the most promising options include Nourianz, XADAGO, and Ongentys.
Martin describes the benefits of each this way: “Nourianz is a good option when patients hit a roadblock with L-dopa or are experiencing low blood pressure or dyskinesia. Both XADAGO and Ogentys can help reduce “off” time and help with symptoms such as shakiness, stiffness, and difficulty moving.”
But Martin cautions, “As is the case with many new medications, these drugs can be very expensive, and it often requires the provider to get prior authorization from their health plan or provider before receiving them.”
For patients who suffer from severe “off” times—even to the point of becoming nearly frozen in place—there are new rescue medications that can provide some relief.
For example, Inbrija, which is essentially L-dopa in powder form, gets around the need to swallow anything by allowing patients to inhale the medication from a kazoo-like device.
Another option, Apokyn, contains a dopamine agonist that works by acting in place of dopamine. Provided in an injectable pen form (think EpiPen), the dosage amount can be adjusted on the device, and it can be injected into the leg or abdomen. Typically, patients come around in 10-15 minutes at which time they can take an oral dose of L-dopa.
Treating Non-Motor Symptoms of Parkinson’s Disease
As noted earlier, there’s more to PD than the highly visible motor symptoms. Successfully treating these is an incredibly important part of every patient’s care plan. “In my experience,” says Martin, “treating the non-motor symptoms has a greater bearing on individual patients’ quality of life than motor issues. In fact, much of the time I spend with patients in appointments is spent discussing non-motor symptoms and how they can effectively be addressed.”
Common Parkinson’s disease non-motor symptoms and medication options include:
- Mood disorders: antidepressants, including Trazodone
- Sleep disorders: Melatonin, Clonazepam
- Constipation: laxatives, probiotics, stool softeners
- Cognition and behavior: Cholinesterase inhibitor
- Orthostatic hypotension (a medical condition wherein a person's blood pressure drops when standing up or sitting down): Droxydopa, Fludrocortisone, Midodrine
- Drooling: Botulinum toxin
Quality Parkinson’s Symptom Management Begins with Quality Symptom Tracking
Regardless of the nature of symptoms a patient is experiencing, key to successfully addressing them is accurately tracking and reporting them. Fortunately, the options for tracking symptoms are as almost diverse as the medications that might potentially be prescribed.
The simplest tools are motor tracking diaries where you can track and record your symptoms throughout the day.
Options include:
A Patient Motor Diary from the Veterans Administration. A paper-based diary, this tool can be printed out for patients to record their symptoms every half-hour.
The ADPA Symptom Tracker is a free downloadable app you can take with you wherever you go. Available in English and Spanish, the app makes it easy to record symptoms and automatically prepares reports that can be shared with your healthcare provider prior to any appointments.
Wearable tech options, including Fitbits and Apple Watches, make it possible to track health-related metrics, including physical activity levels, energy expenditure, and sleep habits. This information can be shared with your healthcare provider prior to any appointments. Additional wearable devices are currently in development that may help better track issues with gait, posture, tremors, and more.
“This type of detailed personal information will make it possible for physicians to tailor treatment to the specific and emerging needs of each patient,” says Martin. “That means we’ll be in a position to better treat symptoms and meaningfully improve each individual patient’s quality of life.”
Talk to your neurologist about medication options for Parkinson’s. Keep track of your symptoms and share the information with your care team to best tailor medication for your needs.