Parkinson's Disease Medications

so we are honored to welcome today dr. tjl Patel to discuss with us of treatment of Parkinson's disease with medications dr. Pedro Patel is an assistant clinical professor at the University of Waterloo School of Pharmacy and a practicing clinical pharmacist with the memory clinic at the Center for Family Medicine family health team in Kitchener Ontario dr. Patel obtained her doctor of pharmacy degree from the University of Kentucky and completed a postdoctoral research fellowship in neurology at the University of illinois-chicago her clinical practice focuses on the pharmaco therapeutic management of neurological disorders her current research studies medication in older adults in particular those presenting with cognitive impairment impairment I'm sorry seizures and Parkinson's disease dr. Patel is also involved in interdisciplinary primary care training of pharmacists for older adults with cognitive disorders dr. Patel has co-authored a little booklet called medication to treat Parkinson's disease it's a new resources that just fresh off the press from Parkinson Canada it's officially launched here today's or you're the first one to get a copy of that and we are pleased to distribute this with you today a complimentary from Parkinson Canada they're all on the Parkinson stable so please join me now in welcoming dr. Sejal Patel [Applause] good morning everybody thank you for coming to this presentation I'm glad to be here speaking about medications and I will welcome questions during the presentation if you feel like you need to me to clarify just stop me so what I hope to do within the next hour or so is very briefly talk about how Parkinson's presents and most people and many of you here are either living with Parkinson's disease or have a loved one with Parkinson's disease so you will be familiar with them any of the things that I'll say today I also want to demystify medications as you all know medications are the mainstay for the treatment of Parkinson's disease so I want to give you some background about how as clinicians we might decide when to start medications which medications do we decide to start with and how we adjust the dosing so I want to I want to clarify some of those demystify some of those things that we do as people who help patients or persons with Parkinson's disease so Parkinson's disease what is it very many times if you're reading up on this what you'll see is that it is called a chronic progressive neurological disorder caused by degeneration of dopaminergic neurons and if I were to explain what that means essentially what it means is that it's chronic meaning once you're diagnosed you live with it for the remainder of your lifetime so that defines the word chronic you're continuously living with it progressive means that over time the symptoms of Parkinson's disease tend to worsen so as many of you living with Parkinson's will notice or will point out is that the sentence may have been one of you when you first or initially got diagnosed and then with time they seemed to progress and so essentially what chronic recive means for us as clinicians is it's a condition that once diagnosed you're living with it for the rest of your lifetime and that we should be prepared to help you manage the the progression of the disease and it's caused by the degeneration of dopaminergic neurons and what that means is that it's caused by the dying off of neurons that produce a certain chemical in the brain called dopamine now dopamine is one of the neurotransmitters or chemicals that is produced in the brain and dopamine helps one neuron talk to another neuron especially when it's related to producing movement it's one of many so there are others there is a acetylcholine that helps with one neuron talk to another neuron when forming memories or recalling memories there is serotonin that helps with mood or eating so as as I wanted to point out those are what dopamine is one of many and dopamine is the chemical that is primarily responsible for producing movement and it isn't just producing movement it's producing fluid movement okay if the disease is named after James Parkinson he wrote an essay he was a physician he lived in the 1800s and back in 1817 he wrote an essay on a group of patients that he had been seeing that had very specific symptoms that they presented with and he was the first one to identify this group of people who presented with similar symptoms and so the disease is named after him as a picture of him that I've given there so when we think of clinical presentation of Parkinson's we usually think of motor symptoms now Parkinson's disease can have motor symptoms so symptoms that are more obvious when you are doing things walking or resting they impact the motor functions there are also non motor functions however with what we have right now in our healthcare system and our diagnosis were limited to diagnosing it when it presents with what we call classical motor symptoms so the classical motor sentence that a lot of people who have this disease present with our tremor and the tremor is a very classic tremor there's lots of different types of tremor but the tremor that's associated with Parkinson's disease is very specific in we call it pill rolling so many of you will tell can show us essentially what that means it feels like you're rolling a pill if you have little capsules you know the tremor is like rolling a pill so we call it pill rolling it's an easy way for us to be able to differentiate the different types of tremor that we may see in clinical practice the tremor also has a specific frequency that we see with it again different tremors can present differently some are very fine some are very obvious this one has a three Hertz frequency it's a way for us to be able to start differentiating it from other tremors that can present with other problems or other conditions in the brain so it's a pill rolling tremor it has a certain frequency and the other thing that we notice is that it occurs at rest there are some tremors that occur when you go to initiate a movement say you wanted to drink your cup of coffee as you initiate the movement your tremor occurs in Parkinson's disease what we noticed is that the tremor occurs when you're resting and when you try to do something or as you initiate movements that tremor disappears again it's a way for us as clinicians to start to piece all of this information together to figure out where this all of these coalition of symptoms can be slotted in terms of a disease process and lastly what we notice with this is that it usually starts with one side of the body not both sides so if someone presents with tremors on both sides they may not they may not it's not that is obvious they may not be as likely to have Parkinson's as opposed to if you at your initial point present with symptoms on one side of the body so we call that asymmetrical it doesn't have symmetry it's asymmetrical occurs with one side now with time as I noticed as I pointed out earlier with Parkinson's disease it does progress so very many persons with Parkinson's their symptoms will progress to the other side but it occurs over time initially you might see the tremor the rigidity the decreased movement on one side and then it might progress over to the other it could start with one what we say extremity what we mean by extremity is a hand or leg and then progress over to the other side what we also see is rigidity what patients may say it's very difficult to get out of bed or persons with Parkinson's may say difficult to get out of bed I'm not as fluid in the morning or fluid during the day as I used to be and as we get older we sometimes tend to think oh it's age but sometimes those are the things that help us recognize that this is the beginning of a process the third thing that is that we look for when we're trying to diagnose Parkinson's or when doctors are trying to diagnose Parkinson's is something called brady kinesia which is just decreased movement you're not walking as fast as you used to you know you you can't get up and go as much as you used to and we also sometimes find a keynesian out akinesia is complete loss of movement and occurs further down the road and usually during the initial phases we're looking for Braddock kinesia now many of you is if you've been diagnosed with Parkinson's I'm sure you have to do a number of things when you were visiting your physician or your neurologist they probably had you write sentences multiple times they probably had you draw a circle and if you're wondering why they're making you do those things is to be able to see if you have bratty kinesia so your handwriting when you write the first time you write a sentence it'll likely be bigger then as you write it repeatedly your spell your sentences get smaller and smaller the amplitude or the size of your letters get smaller and smaller and that helps us recognize bratty kinesia when you draw your circles they're looking for those little squiggles but they're also looking to see if your circles are getting smaller and smaller as you drawing them we also look at your face to see are you blinking as often as someone without Parkinsons blinks because we also know that you're blinking decreases when you have Parkinson's disease and we may also be looking at your face to see can you express your emotions as easily as someone who doesn't have Parkinson's I'm sure a family members of people who have Parkinson's I've told you it's not easy to see what you're thinking because the ability to express what you're thinking and your emotions decreases and that is all happens because of a loss of dopamine that you need to produce the muscular movement in your face so it's a similar thought process in terms of dopamine's effect on the motor skills and finally what we may also look for is postural instability we may pull you backwards and see if you can stop yourself from walking backwards or we may ask for Falls or dizziness now postural instability basically means you're not as stable as you're standing essentially occurs later on in the disease process and isn't it isn't a finding that you find early in the process these are the things we're looking for usually you need two out of three to be able to diagnose Parkinson's disease and so if that kind of explains some of the things that your physicians may have done when you were visiting them now there is also something called non motor symptoms of Parkinson's disease now non-motor symptoms essentially is exactly as it says those are symptoms that are not motor related or movement related and they may occur or may start years before you're diagnosed with Parkinson's disease a big example is the loss of smell that may start 1015 years before you're diagnosed with Parkinson's and we've begun to recognize that almost 25 one out of four – almost four out of four different studies report different numbers may have the symptom and so we're trying to understand if that's a way we can recognize Parkinson's even earlier it's still in its research it's not applied in clinic clinical diagnosis as much right now but we've recognized that the loss of smell may predate your motor symptoms and so that may be one way to examine and determine people who have Parkinson's other things that be a person with Parkinson's will report is fatigue or tiredness many of you will talk about how tired tiring it is and how tired you get through the day a number of people will also talk about mood issues so depression anxiety and sometimes anxiety is related to the motor symptoms and being able to control the motor symptoms but we've realized that depression sometimes also predates or can also occur with the diagnosis of Parkinson's disease because it is a life altering diagnosis very many times many people will also report something called REM behavior or REM sleep behavior disorder so problems with they may say things about having to walk at night and being restless at night or kicking their partners they may not recognize their partner they're kicking their partners but their partners will report he kicked me at night or she she kicks me at night so that also we've discovered that there is some relationship between Parkinson's disease and those kind of Sleep Disorders we're recognizing more and more that there is a relationship that we need to investigate further and finally a lot of patients may have been reporting constipation predating their motor symptoms but nobody thought about putting it together because as we all know constipation can occur for a number of reasons but again we've realized that some of these symptoms may start presenting even before you see the motor symptoms present and so that we need to pay attention to those kind of clinical symptoms as well now as a pharmacist I was taught to always look when a person comes to me and complains of a symptom whatever it is I was taught to always look at their medication list to see if it's medication related and so with Parkinson's disease there are a huge list of drugs and I don't expect you to go away remembering it all but as just a way to show you that there are medications that can produce the same symptoms as Parkinson's disease we call this drug-induced Parkinson's disease so anytime you have a symptom it's always a great point to sit down with your physician or your pharmacist and say is there a medication on this list that could be responsible for this symptom and really it's not only for Parkinson's is for any new symptom I'd recommend that you sit down with your physician or pharmacist and say can you look at the medications I'm taking to see if any of those can cause the symptom I'm having it's always a good idea to ask that question because in people with Parkinson's sometimes use of these drugs unmasks what we say unmasks underlying Parkinson's so these people have Parkinson's disease process underlying and ongoing that we have in recognized because it hasn't presented as a motor symptom and once people take especially the drugs listed in the high-risk column then those symptoms become prevalent and then we recognized oldest person has Parkinson's but in some people they don't have a Parkinson's disease process and these drug produces those symptoms so if we don't recognize that it's a drug causing the disease and then we treat the disease then that's a double whammy you're on to drugs you may not need now you must never stop any of the medications if you think they're related because some of these cannot be stopped suddenly they'll produce what we call rebound or problem that we hadn't recognized would happen if you suddenly stopped so if you think that there is a medication that's related before you stop it always talk to your doctor if is it is thought to be related then they will help you figure out how to come off of it slowly but never stop anything suddenly unless you feel like it's going to harm your life I always say make an appointment with your doctor or even better your pharmacist you can walk up to the counter and say I'm having this what do you think about this what do you think I should do okay so what about starting treatment how do we decide when to start treatment how do we decide why so when we are looking at starting treatment and when I say treatment I mean specifically drug treatment for Parkinson's disease as we know there are other strategies we can use to ameliorate or lessen the symptoms of Parkinson's disease that are not drug related but what time or when do we start treatment for Parkinson's disease there is no perfect time there is no magic time when your doctor says this is it for you will you reach that point it has to be done in a shared decision-making process and what I mean by that is you have to be party to that decision and usually what we find is persons where Parkinson's decide the time for starting a drug treatment is when it starts impacting quality of life so if someone feels like it's causing their tremor or their rigidity or their clumsiness related to motor sentence is causing them social embarrassment or is impacting the kind of work they do and their ability to continue working if those are the points at which we usually start treatment and which medication we start again there is no magic drug that we start with it all depends on how severe your symptoms are how much they're impacting you what type of symptoms you're presenting with you know of all those four different types I listed earlier on sometimes the treatment is based on which of those are your predominant or primary problematic symptoms and also an important thing to remember is the age some of those medications are not appropriate for the older adults and as we age they cause more problems and they cause other symptoms that need to be treated and they may be less adverse effect causing in a younger population so when you're sitting with your physician they're thinking of those things in terms of what kind of symptoms how bad are the sentence how badly are they affecting this person how old are they are they a robust healthy you know marathon running eight-year-old or are they more of frail six year old that will determine which option they may decide to present to you as an option to start it's always a good idea to go in well-equipped with information so that you can talk about all of these options and I hope that some of this will help you get that background to be able to chat with your physician now there are about seven different classes that I've listed we call them by their activity so what they do in the brain is usually how we label drugs the first class I have listed there our monoamine oxidase B inhibitors there's two on the market for that there is saline and rescheduling which is also called as elect then we also have anticholinergics arcane and co gentle now these medications are very problematic and the evidence or the quality of evidence supporting their use and Parkinson's is not very good but we used to use it and some people found it effective so we still keep it in our our material box our box of weapons too to address this but there as you age they cause more problems so they're not used as often these days then there is a class called dopamine agonist that kind of pretend to be like dopamine but they're not really dopamine then we have a class called the dopamine precursors and you most of you will be familiar with this class all we use this in almost all persons with Parkinson's at some point in their life journey with Parkinson's and that's levodopa Sinemet or pro lopa at some point you will be using that medication then we have others called catechol or methyl transferase inhibitors and we purposely make these really mouthful so that nobody can save them and you have to go to pharmacy school for four years to learn to save them the one of the markets that we use frequently is Compton then there are the N methyl dose NMDA antagonist I wouldn't even attempt to say that and then we have some combination products where they've combined different mechanisms of action or different ways the drugs work into one pill so you don't have to take as many pills you get all drugs in that one pill now what do these medications do how do they work so we've targets targeted several different areas and this looks like a complex slide so I'm going to break it down for you is and try to provide some clarity so if you look at the straight line on the screen the the line going down that's called your blood-brain barrier and sistine line of cells that protects your brain and outside of your brain there is dopamine so dopamine exists inside and outside of your brain but dopamine cannot cross the blood-brain barrier okay so when it exists outside the brain it has no way of going into the brain and we need as as I mentioned with Parkinson's it's the dopaminergic neurons that are dying off and we need more dopamine to keep us moving fluidly so as they're dying off there's less dopamine being produced so how do we get the dopamine outside of the brain into the brain if the blood-brain barrier won't allow us to get in now what it does what the blood-brain barrier does allow the bread allowed to get into the brain is something called levodopa and levodopa is the chemical substrate before the dopamine it actually gets broken down into dopamine and the brain will allow levodopa to get into the brain now as you all know you all as many of you know you take levodopa now levodopa when you take it it gets broken down really fast into dopamine and it can cause side effects such as nausea that's the the levodopa bring broken down into dopamine so the reason that you have products such as cinnamon and pro lopa is they're both combination products Pro lopa is with a product called Ben's a Sur ID and cinnamon is levodopa combined with carbon opa and the reason we put those in with the levodopa is because they stop the breakdown of levodopa so if you can stop the breakdown of levodopa outside of the brain then you allow more levodopa to get into the brain and then the levodopa can get broken down into dopamine and therefore you have dopamine that can help with activity and motor activity so both carbidopa and a Ben Zakai right we call them dopa decarboxylase inhibitors they stop the enzyme that breaks down the dopamine or that breaks down the levodopa into dopamine the in tactics intact apone does a similar activity as well so that more levodopa can cross the blood-brain barrier once levodopa is in the brain so that will be on the right side of your screen there it gets broken down into dopamine and then other other metabolites we call them it once it's broken down into dopamine it can get further broken down so you don't want dopamine to get even broken down even further so that's where saline and recycling come in they stop the dopamine in the brain from being broken down so you have more dopamine floating and useful okay and finally on the other end so if the top parallelogram is your presynaptic neuron is your neuron that's trying to talk to the postsynaptic neurons at the bottom on your right hand side is the parallelogram that's a postsynaptic neuron I don't even know if it's a parallelogram I might be using the wrong term but I think you know what I'm saying you want to get the dopamine from the presynaptic neuron to the postsynaptic neuron so that you're able to produce a movement okay so you want the dopamine your dopamine is actually the communicating agent between your presynaptic and your postsynaptic and the dopamine agonist actually pretend to be dopamine and they sit on the gates on the postsynaptic neuron telling the postsynaptic neuron hey and dopamine send my message when they're not actually dopamine does that is that clear yes okay so as I mentioned when we're thinking of starting treatment we look at severity so we usually try to the questions that a physician may ask you is you know how are your symptoms affecting your life on a day to day basis do you find the mild do you find them severe what is it about the symptom that's preventing you from carrying out your day to day activities how's the tremor affecting you how is the slowness or the rigidity affecting you and then finally as I mentioned we also look at the H to see if the person sitting in front of us is going to be able to tolerate the medication that we're starting because all medications have side effects okay so when we think of age 60 and older if you have mild brady kinesia or if you have mild postural instability we may go with a monoamine oxidase B inhibitor that's how we might start treatment if we think the symptoms are mild and we want to keep the other drugs in our toolbox for later on let's start with the monoamine oxidase inhibitor it has few side effects it's tolerated very well it'll keep the mild symptoms at bay up to a point where we might need to use one of the bigger guns in the toolbox if you have severe symptoms severe braddock kinesia postural instability or tremor then we will go with one of the big guns which is levodopa levodopa is very effective in treating the symptoms of Parkinson's disease as you all very well know if you're younger than 60 years old then we have a few other options available so if you have tremor as your predominant or your most problematic symptom we might go with a dopamine agonist or levodopa and most clinicians will usually go with the dopamine agonist as opposed to levodopa now I've listed anticholinergic there because in some people the use of an anticholinergic is very effective in treating that tremor however as we age we find that anticholinergics do start affecting ability to remember they cause memory impairments they cause constipation they cause dry mouth so we might limit that if you have if you're younger than 60 and you have mild symptoms again you see that the monoamine oxidase B inhibitor is the first agent that we would try if you have severe symptoms then we're going to target one of the bigger guns dopamine agonist or levodopa and the reason we have that in it the age is really an arbitrary cutoff for each clinician they may use a different age or they may truly just look at the person sitting in front of them to decide which way they should go with dopamine agonist if you use it in older people they have a higher rate of producing symptoms such as hallucinations or sudden sleep or orthostatic hypotension which is a sudden drop in your blood pressure and that's why we try to tend to use them in the younger population as opposed to older now it doesn't mean that you can't use them at all we just in the older population we just have to be more cautious and do more monitoring if we use those agents in the older population yes dopamine agonists so anything that has an effect on dopamine they all have similar side effects because it's the dopamine that's related in the blood pressure in the hallucinations in the side and sleep so they all carry the risk but dopamine agonists and appear to carry a higher risk and so we try to limit their use in the older population okay and as you will also know that we also try to adjust treatment for Parkinson's disease and we are continuously doing this as we go through the go through our life with Parkinson's if we give an agent and it's not effective and it causes no side effects we just tend to continue and we don't want to rock a boat that's sailing it's the point at which we start seeing side effects or we see that it's not as effective that we start thinking of strategies about how to adjust dosing and again there is no magic formula there is no algorithm that works for everybody for each person a different combination of things is going to work so adjustment is going to be based very much on the person that's sitting in front of you as a clinician so if you started on an anticholinergic we might add a dopamine agonist if this results in good control always I'm a believer in using as few medications as you can because the more medications you use the higher the number of drug interactions etc etc the higher potential for side effects so if the dopamine agonist is working that's a good point to sit down never do it by yourself is to sit down and discuss whether you should come out your anticholinergic whether that is a potential or that's where we're going to move towards if this does not work we might change to leave a dopa so sometimes you might feel like we're doing a lot of changes but truly what we're trying to do is find the medication that works best for you and we have some ideas about which type of patients they may work for but it doesn't work 100% of the time so really with every person we're trying to figure out which works best for them if you started on a dopamine agonist you'll see that we move to one of the other agents levodopa or an anticholinergic and if you started with levodopa usually if you start with levodopa we don't tend to discontinue that because we know that that will be required long term we usually try to add other agents we might decrease the dose of levodopa while we're adding other agents but generally once you're on levodopa is very difficult to come off of levodopa and so we try to prolong the time to starting levodopa with the other ages and similarly with the other symptoms with age again is either looking to see what you're on and then trying one of the other ages and we'll usually start at a small dose and then try to target a dose that affects you best so affects your motor control without side effects so it's usually it's like a say what's the right terminology it's um I'm skipping out on words it's a trial and error for every person to try to see which dose might work best for them so as I mentioned adverse effects of dopaminergic agents are related to the dopamine overtime what we do see with levodopa is something that we call motor complications so you might see fluctuations in how your dose of levodopa is working okay it may wear off earlier than it used to very many people will say that it doesn't last as long as it used to just the last four hours or use the last six hours and now it's lasting three hours or five hours so that is something that happens with levodopa we also see a dyskinesia so if you think of water running over a turbine you need the right rate of water over running over the turbine so the turbine flows smoothly if you increase the amount of water and the pressure running over the turbine the turbine might spin too fast so similarly sometimes there is too much dopamine and it might cause dyskinesia and so we've got a ensure that we're dosing and adjusting dosing so you don't have dyskinesias but you still have motor control and fluidity in your movements we've also seen impulse control disorders and I'll talk about that with dopaminergic agents and then I also mentioned nausea that occurs when you take a dose as well as hallucinations that can present at any age but it can present in the older person now when we talk about motor complications I mentioned on periods you might hear a lot of clinicians asking when are you on and essentially what they're asking is yeah when you have complete control of your movement and when your movements are fluid then there's the off period those are the times when you see that the medication is not working as well and that the effect of the medication is diminished your movement is not as fluid you're seeing a return of your parkinsonian symptoms such as tremor rigidity bratty kinesia motor fluctuations are such with your on an office those times when you start seeing that the effect of the drug doesn't last as long as you'd used to or that you're having dyskinesias in between when you're taking your doses and dyskinesias as most of you will be of aware with are those are movements you can't control so you have movements you can control and then you might have other movements that you can't control especially when it's some it's their non-rhythmic their jerky movements okay and then of course when I refer to impulse control disorders I'm actually talking about these agents increasing the risk of uncontrolled gambling uncontrolled eating or compulsive shopping we've seen those kind of things also happen with dopaminergic agents so in terms of how do we address this so really the the treatment of Parkinson's disease is very much how to keep you in your fluid state good motor control without having side effects so when we see these side effects what are the thought processes that we have in terms of treating this so the first is if you as are given a dose of cinnamon and you have no effect it doesn't address your symptoms at all then we're going to question the diagnosis cinnamon is very effective for Parkinson's but the symptoms that look parkinsonian don't only occur with Parkinson's disease there are a whole host of other conditions that are also related to parkinsonian symptoms and sometimes in some people is very difficult to clearly understand what it's related to from a clinical perspective so if cinema's doesn't work we're going to start investigating whether it's one of those other conditions and we have no magic test no scan no blood test that tells us yes this person has Parkinson's disease so sometimes we are working with the information that we have trying to make a decision based on how the information is presented if you see that your response is there you have some response but it's not the that you're looking for so you've seen some improvement in your motor symptoms but not the level at which you were hoping to achieve then you can talk to your doctors about if you're on leave it over how to increase that dose how to increase the frequency if you're on one of the agents which are the other agents you should try adding so that those problems can be addressed in terms of delayed on I'll hear a lot of persons with Parkinson's tell me it used to work straight away but now it takes an hour or two to start working and that may be because the the pill is not moving as fast through your gut and so it's not getting to that point where it's dissolved and absorbed as fast as it used to a couple of years ago so or it may be that you may be eating more protein and so protein kind of interacts with dopamine and doesn't let the dopamine levodopa get absorbed and so you're having you're not seeing the effect that you used to because it's taking longer to get absorbed okay so some of the options we might think of is increasing the dopa the dose of the drug or the frequency so changing the time of administration one thing I always tell persons with Parkinson's as well as some of the physicians I work with is try to limit the use of the controlled release formulation what we've seen in studies is that the absorption of that formulation is very erratic from one person to the next and from one dose to the next sometimes the person may see an effect immediately and sometimes it takes hours and so the absorption of that formulation is very very difficult to to pin down so I try to limit the use of that formulation to only at bedtime so that you have some dopamine when you're waking up to be able to get moving and take your next dose and that's the only place that I see that formulations good use dosing on an empty stomach so you know making sure that you're an hour an hour and a half away from any meals that you've had heavy protein some of the people that I work with wear Parkinson's tell me swear by taking their medications with a carbonated drink so with coke or sprite they say it increases the the time and not increases it decreases the time to when it starts working yes one to one and a half hours so if you've had a meal with a protein reach me at rich meal then I would wait one and a half hours or so before taking my pill so you've got it if you have to take your pills at certain times then you have to plan your meals around those times in terms of when you're going to have something that's a protein snack related to when you need your dose does that make sense okay yes oh you can't hear and my apologies so the question was when if I could restate what I had just stated about protein and separating the dose from the protein snack yes so the question is what is it about the carbonated soft drink that increases the absorption rate I'm not certain probably has to do with most of the carbonated drinks have some acidity to them so I'm thinking that it actually has to do with the pH balance in your gut or your stomach but I honestly don't know I honestly don't know but I've heard that it helps yes and I also said they're welcome to ask me questions look I'll continue on so in terms of wearing off or end of those phenomena when you come across that again talk to your doctors about adjusting the dose of levodopa so increasing the dose if there is no dyskinesias or increasing the frequency of administration if you see dyskinesias but decreasing the dose so essentially you might be taking doses sooner but you might be taking less of the dose so that you don't have dyskinesias and dyskinesias usually occur when the dopamine goes a bit too high if you have wearing off at the beginning of the day so you you're waking up with your symptoms it might benefit you to take a controlled release formulation at the point when you go to bed so that there is some dopamine remaining in your body when you're waking up so that you can get moving some people have to get up at night to take a dose so that they're able to get up and get moving in the day adding a dopamine agonist if you're not on a dopamine agonist again once you achieve a good dose it's always a good idea to decrease the dose of the medication you were on before to see if there's lower doses that can help you with your symptom control and you're not taking high doses of both medications again requires some discussion with your clinician so that you can decide how to do that and at which point your treatment if your symptoms are controlled best adding a compton head of it if you do that then as a pharmacist I always talk about adjusting the dose of levodopa because sometimes that might be too much dopamine so we always talk about how much to decrease the levodopa dose by if you're adding a comped inhibitor and again adding a monoamine oxidase inhibitor is always also an option persons with Parkinson's may also experience something called freezing this is also another motor complication and it can happen with any movement thankfully it usually lasts a few seconds to a few minutes but in some people it can be a problematic issue sometimes it helps to adjust the dose of levodopa and it may be related to not enough dopamine in the brain and then there are people who've told me that sometimes putting cues on the ground so if they're having problem walking putting a cane or a line helps the movement initiate so sometimes working with your occupational therapist or your physical therapist to find those magic things that may work for you may also be a good idea and since I've almost read it out of time so motor complications dyskinesias if you have just recently been diagnosed with Parkinson's disease then maybe we just need to adjust the dose of levodopa I'll finish off and then I'll get you I'm sorry I'm just going to try to get finished with this with advanced disease it's difficult to manage as many of you may know because it requires some very very very fine tuning of the levodopa and your other medications so that you have smooth control but it doesn't push you over into too much dopamine and dyskinesias so again reducing the dose of levodopa reducing it and adding a dopamine agonist using a CR formula if you're using a CR formulation to move to an immediate release formulation adding compt inhibitors or monoamine oxidase inhibitors and then finally what we may also consider is adding amantadine and amantadine this is a point where we actually see its best effectiveness is at the point of dyskinesias I've listed some thoughts about what to do as one experiences hallucinations or constipation or orthostatic hypotension with hallucinations if they're mild symptoms we may opt not to do anything I once was working with a person with Parkinson's and her hallucination was seeing her teenage daughters at the dining table and so we opted not to treat that hallucination because it was not a problematic issue but in in some patients it may be some persons it may be a problematic issue and it may need to be treated especially if it's if it causes them anxiety or if it causes fear in that case what we're generally trying to do we don't want to start adjusting Parkinson's medication straight away especially if they're controlling movement so we may look at other medications and see if there are other medications that may be impacting those hallucinations so for example sometimes anticholinergic medications sometimes beta blockers now there's specific beta blockers that we use for the heart that sometimes produce hallucinations of that from that perspective if pharmacists will approach those and say which of these can we manipulate maybe reduce the dose to ameliorate some of the symptoms of hallucinations again discussing all of this with your doctor constipation the non medication route is best increasing fiber increasing fluid intake improving physical activity if you're on medications that are anticholinergic reducing the dose or discontinuing them and then discussing treatment options with stool softeners laxatives etc with your physician and finally sometimes we may even use domperidone I see a lot of youth adult perdón to improve constipation and to improve the transit time for food in persons with Parkinson's if you have if you're experiencing orthostatic hypotension and what I mean by that is sudden drops in your blood pressure where when you're going from a sleeping to a sitting position or sitting to standing you get dizzy and unstable that can occur not only with medications used to treat Parkinson's but with Parkinson's itself so again then we were looking at are you on any medications to treat blood pressure maybe that's and that's something that we can fix decrease those doses or decrease those medications so they don't cause as much as an impact we're also going to look to see are you drinking enough fluids do you have salt enough salt in your diet the only place where we as professionals will say increase the salt intake most of the time you've heard in your life decrease the salt intake but and there's some other options I've listed avoiding large meals avoiding alcohol avoiding warm areas elevating the head of your bed so that you're not lying flat on the bed and then moving slowly from whichever position you're on so do it doing things with thought and with care and if all of those fail then there are some medications that we can use usually fludrocortisone or my children for treating that and some additional factors to consider nausea advisee advise people to take the pill with a non protein snack so that the nausea is limited if it occurs always as I mentioned earlier separating your protein from your doses or taking it with a carbonated drink never stop your medications suddenly always discuss with your doctor and they'll tell you how to taper or your pharmacist they'll tell you how to stop it slowly with the brain any medication that affects the brain is very important that we do things slowly start at a small dose and slowly increase and then Melissa and then slowly come off of those medications as well it's very important to remember to do that and then finally there are some drug interactions that I wanted to point out to you some of these because they're available over-the-counter you can go and pick them up and you've not had a chance to chat with somebody then you may not know that they're interacting with your medications for example antacids because they decrease the absorption and when I say bioavailability is the amount of drug in your body so always before you decide to take an antacid if you have a medication list walking to the pharmacist at the counter and say is this going to be a problem okay and there's too many of those for me to be able to go through all of them anticholinergic medications is a class but there's lots of medications within that class so for example medications that you can find over-the-counter like benadryl is a huge anticholinergic medications such as a level or amitriptyline or nortriptyline that we use to treat sleeping issues they also have anticholinergic effects so it's again to larger list to mention all of them I talked to your doctor or your pharmacist about those potential side-effects antihypertensive medications when we're younger most of us will get diagnosed with a blood pressure or hypertension and we'll get placed on medications and then as we age our blood pressure either isn't as elevated or starts to fall so we need to especially with Parkinson's disease we need to think about whether we need to continue those medications as well antipsychotics and metoclopramide metoclopramide is also used to promote GI motility or you know transit time within the gut but that one has a big effect on dopamine we call those anti dopamine or dopamine antagonists and they actually block the dopamine receptors in in the brain and cause symptoms similar to Parkinson's disease and most almost all antipsychotics do that too so again we need to think about that when we're thinking about Parkinson's medications and anything that contains iron will decrease the absorption of parkinson's medications or levodopa so again it's the message I can send away is take your medication lists everything you're taking herbal products over-the-counter prescription to your physician or your pharmacist and make sure that there is no interaction that's affecting the control of your parkinson's or anything else and i believe that is it and i can open it up to questions thank you very much I just want to say we have about a 10 minute question period so you can raise your hand and someone will come with the microphone and I would ask that one after the question period please remain seated we will do a rapid lunch box distribution so we know how many is needed please remain at your seat you'll receive a lunch box and then you're free to roam and go and meet the exhibitors go to washroom grab coffee in the hall if you wish so it should be fast I will call all volunteers and staff to distribute the lunch boxes so now raise your hand for questions thank you um well I would put on Sinemet and um when I was on three milligrams like um um three tablets leave with each meal my blood pressure would drop and what I will collapse so my neurologist brought me down to two and a half milligrams so I wouldn't pass out no falling asleep is that caused by Parkinson's or the medication sentiment so it could be related to both it has also been related to the medications that you use to treat Parkinson's we've definitely seen sudden sleep associated with dopamine agonists those two that connection has been made sleeping falling asleep having sleeping problems is also associated with Parkinson's as well so very many times it's very difficult with Parkinson's disease as well as Parkinson's medications to truly say it's one and not the other very many times it's probably a correlation between the two so I shouldn't be surprised that if I'm at a lecture or I'm sitting singing in synagogue and I like not off um if I had Parkinson's or taking cinnamon I should not be surprised this is happening no you should not be surprised but you should mention it to your doctor because if it's a problem and you really want to pay attention to what's going on then there might be something that he can do in terms of adjusting your dose I just want to add a little something that may help you answer all of your questions a year ago in this very room we had a whole conference on sleep disorder sleep problems in Parkinson's it was taped and it's available on YouTube if you go on YouTube you can prompt Parkinson doctor pass to MA or Parkinson's sleep disorder it's a one-hour conference very comprehensive specifically on that topic so maybe that could help you because I would suggest we maybe give the microphone to others thank you thank you could you explain again very quickly about Mt ecology anti colors anti combinations yes and what you said about that and the other question is having to do with proteins and medication and I didn't quite so eggs are out kind of thing okay so the first question is I assume what are anticholinergics and how they affect a person an older person so anticholinergics are it's a very broad term we give a number of drugs and they can be drugs such as antidepressants they can be medications used for sleep they can be medications used for anxiety for nausea and the reason we call them anticholinergic is because they work on the cholinergic system on the acidic colon system in the in the body and when you block some of those acidic colon receptors you produce things such as constipation dry mouth dry eyes but the most important we feel is also memory impairment so acidic choline is like dopamine it's a neurotransmitter it's the chemical that's responsible for us to be able to create memories to be able to remember and when we block that receptor with an anticholinergic were not able to form those memories and so there is a number of drugs out over-the-counter medications as well as prescribed medications that have bad effect and sometimes we don't recognize it straight off that they have that effect we actually have to look at how it works to be able to determine that and that's why it's a very long list and even within those anticholinergic medications there are ones that are no anticholinergic and they're ones that are high anticholinergic so for example benadryl i put it as a high anticholinergic but something like celexa has very low anticholinergic so it's just that they can become problematic you a person does not want to have Parkinson's and then start having memory issues related to a drug so or constipation when they already have that as an underlying thing that happens with Parkinson's now your second question as related to protein is that protein decreases how levodopa is observe absorbed so what it does is it doesn't decrease the amount that it's absorbed but it increases the time within which it gets absorbed so you don't see as much levodopa straight after you take it if you take it with protein as you would if you didn't take it with protein so ultimately you might have the same amount of levodopa over time but then you don't reach that peak or the the amount that you need for it to produce an effect in the frame that you're in the timeframe that you need – does that answer your question so eggs are not out you just need to separate it I just want to add as shown in your handout that there will be a webinar specifically on nutrition and Parkinson's and such issues will be addressed it's going to be on May 11th you can go on parkinson's website and register and also will address a bit of protein intake and drug interaction in the panel this afternoon so yeah thank you hi over here if I may ah yeah I've seen I work with folks with Parkinson's and I've seen several folks that have difficulty sequencing events is there a is there treatment for that is that drug-related doing okay so you're talking about sequencing as in memory your executive function yes yes so Parkinson's disease over time there is something called Parkinson's related dementia that occurs and it occurs after several years of having Parkinson's there may also be other spectrum of disorders called Lewy body disorders and they all fall on the memory problems so executive function or sequencing apps fall on the memory problems and it can be related to a medication if they're on a medication such as an anticholinergic where you can also be related to having Parkinson's or having a Lewy body spectrum okay other questions yes hello we didn't mention the new foe patch yes that one already included in the type sir so new Pro patch I have it as one of the drugs in my slice is a dopamine agonist so it's like your pramipexole and your rope in oral it's formulated in a patch so you don't have to take pills and you leave the patch on either you can place it in several different areas of the body for 24 hours it works very much like other dopamine agonists such as primary Texel and rope in oral it also has to be adjusted so the patches come in different strengths and you'll have to go up and if you're coming off you have to go down hi there um if you take Don para doll and reduce constipation can that increase dyskinesia Don para dome not necessarily because it does not get into the brain at you only works peripherally or outside of the brain so you should not see an increase in dyskinesias what may be happening is that more of the levodopa is getting absorbed because you're improving transit time and that's related to the dyskinesias okay so it might be involve a discussion with your physician about how to adjust yes what is the situation on research on medical marijuana with respect to education so research is ongoing I don't believe that we've reached a firm conclusion on its effect in terms of marijuana and the effect on Parkinson's disease as in symptom control of Parkinson's there is some research that it may help with pain but I actually don't know enough about how it helps with pain to be able to conclusively tell you how effective it is and is there a seminar I just want to add that there's been recently a webinar exactly on that topic Parkinson Canada invited a young expert on all different issues of Parkinson's medicinal marijuana appointed Parkinson's in this case if you go on Parkinson Canada's website or even on YouTube you can access the rerun so I invite you to have a look at that webinar and it's very very comprehensive and it's going to show you where are we up to date with that issue all right so I think we'll have to move on with our program I'm sorry there are many more questions I invite you either to discuss with us during lunch time or to keep your questions for this afternoon there will be opportunity to ask questions after the panel after the conference on physiotherapy there'll be a panel and there will be a last question period at the end of the day so please keep your questions and thank you for remaining seated so we can distribute lunch box so I want to thank you dr. Ettinger Patel for this excellent presentation [Applause]

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