At the Neurological Institute on the CHI Health Immanuel Medical Center campus, we take a collaborative practice approach to the treatment of Parkinson’s disease. Our neurologists work closely with a Doctor of Pharmacy from Creighton University who specializes in the pharmacologic treatment of neurologic disorders. Patients have individual appointments with their neurologist, and also with the pharmacist who continues to see them on a regular basis. As a team, they make treatment decisions to ensure patients achieve the best outcomes. This approach is unique to CHI Health’s Neurological Institute, where we recognize that collaboration between the specialties is the best approach to ensuring that patients with Parkinson’s disease get the finest and most comprehensive care possible.
Medications for the control of the motor symptoms of Parkinson’s disease remain the cornerstone of treatment. In general, medication therapy focuses on the replacement and regulation of the activity of the neurotransmitters (primarily dopamine, which is involved in the control of movement). The choice of medications is highly patient-specific, and is dependent upon many factors including the severity of symptoms, the presence of other pre-existing medical conditions, the age and current needs of the patient, and the potential for interactions with other medications that the patient might be receiving. The goal is always to achieve a balance between symptom control and side-effects.
Carbidopa/Levodopa is one of the oldest medications used for the treatment of Parkinson’s disease. The medication is given as a direct replacement for dopamine. While it remains the most potent medication for the treatment of Parkinson’s disease, it has the potential to induce involuntary movements called dyskinesias after several years of exposure. The introduction of this medication for a patient is therefore carefully timed.
Continuous infusion carbidopa/levodopa
Recently, a new formulation of carbidopa/levodopa given by continuous infusion into the gastrointestinal tract has become available for patients with very advanced disease. A specially trained team of practitioners is available to provide this new formulation to eligible patients.
Dopamine agonists are a group of medications that work like dopamine in the body. They are less potent than carbidopa/levodopa, but are good options as initial therapy for many patients in the earlier stages of the disease, or as an addition to other medications as Parkinson’s disease progresses. They can also help increase the effectiveness of carbidopa/levodopa when the effects of the latter start to diminish due to disease progression.
MAO Inhibitors and COMT Inhibitors are used in the treatment of Parkinson’s disease to constrain the activity of enzymes involved in the metabolism or breakdown of dopamine. In this way, they can enhance the effect of dopamine-replacing medications, and also the patient’s own dopamine. MAO Inhibitors are sometimes used alone early in therapy, but they may also be added to other medications as the disease advances. COMT inhibitors are only used in conjunction with carbidopa/levodopa.
Anticholinergics are the oldest medications used in the treatment of Parkinson’s disease. They do not affect dopamine or dopamine receptors directly. Rather, they work to correct the imbalance between dopamine and another neurotransmitter called acetylcholine. The overactivity of acetylcholine is believed to play a role in the tremor that is characteristic of Parkinson’s disease.
Amantadine is a medication developed for use to prevent and treat influenza. Its ability to help patients with Parkinson’s disease was discovered by happenstance during clinical trials. It is generally not used long-term for the treatment of Parkinson’s disease as its effects tend to be mild, and the disease usually progresses beyond the ability of the medication to control symptoms fairly quickly. However, the drug has been found to be helpful for patients who develop carbidopa/levodopa induced dyskinesias, or involuntary muscle movements.
Treatment of the Non-Motor Symptoms of Parkinson’s Disease
Though we usually think of Parkinson’s disease in terms of its classic symptoms (tremor, rigid muscles, slow movement and problems with balance), there are a number of other associated conditions that patients may face. The following symptoms are frequently experienced by Parkinson’s disease patients:
- Psychiatric diagnoses (depression, dementia and psychotic symptoms),
- Low blood pressure/dizziness
- Gastrointestinal dysfunction (constipation and nausea)
- Sleep disorders (restless legs, insomnia or excessive sleepiness during the day)
Sometimes these problems are directly related to the medications that we use to treat Parkinson’s disease. Other times they are experienced as part of the disease itself. The neurology care team can help patients navigate these complications with careful medication adjustment, and the addition of other treatment strategies when necessary.
Treating Advanced Disease
Because there are currently no medications that have been proven to slow the advancement of Parkinson’s disease, eventually other strategies may need to be employed. Surgical procedures are sometimes utilized to help control advanced Parkinson’s disease.
Deep Brain Stimulation
One such procedure is the implantation of a device called a deep brain stimulator. This device works through electrodes that are placed strategically in the brain. Other surgeries may be done to decrease activity in areas of the brain that are responsible for causing tremor.
Medications for self-injection by the patient may also be employed to combat resistance to drug therapy that develops with Parkinson’s disease progression. Our skilled neurology team can work with patients and caregivers to determine if any of these interventions is the appropriate one, and implement the chosen strategy to maintain the functional ability of the patient for as long as possible.