No standard treatment exists for the earliest symptoms of Parkinson's
disease. In fact, the optimum time to begin treatment and even the best
medication to use is controversial.
Some doctors may begin drug treatment at the first signs of the disease.
Others may delay giving medications until symptoms become more
pronounced. That's because the benefits of traditional Parkinson's
medications diminish over time. Although drugs such as levodopa improve
symptoms initially, long-term use frequently causes excessive, spasmodic
movements (dyskinesia) and other side effects. For that reason, if your
symptoms are mild, your doctor first may try lifestyle changes, such as
diet, exercise and physical therapy.
Physical therapy can be extremely helpful for people with Parkinson's
disease both in the early stages and later, as the disease progresses.
It can help improve mobility, range of motion and muscle tone. Although
specific exercises can't stop the progress of the disease, improving
muscle strength can help you feel more confident and capable. A physical
therapist can also work with you to improve your gait and balance. For
many people, working with a speech pathologist can help improve problems
with speaking and swallowing.
When lifestyle changes are no longer enough, your doctor will likely
recommend certain medications, either alone or in combination.
Medications are used to help manage problems with walking, movement and
tremors by increasing the brain's supply of dopamine. However, your
medication needs may change over time and the drug dosage and timing may
require adjustment. For these reasons, you and your doctor will work
together to design a program that best suits your needs, especially as
the disease progresses. The medications used to treat Parkinson's
Since its introduction in the 1960s, levodopa has been considered
the gold standard drug therapy for Parkinson's disease. Levodopa is
the formulation of a chemical found in plants and animals that is
converted into dopamine by nerve cells in the brain. The increase in
dopamine may reverse many of the disabling symptoms of Parkinson's
disease, but as time passes, side effects may increase and you'll
need adjustments of the doses.
dopamine itself isn't possible, because dopamine doesn't cross the
body's blood-brain barrier. This is a meshwork of tightly packed
cells in the walls of the brain's capillaries that screen out
certain substances. Levodopa, on the other hand, does cross this
barrier, but only a small amount actually reaches the brain.
Combining levodopa with another drug, carbidopa (Sinemet), causes
more levodopa to get to the brain and helps reduce some of the side
effects of this therapy. Sinemet CR is a prolonged-release version
of this drug.
treatment, side effects from levodopa therapy are usually not a
major problem. But as the disease progresses, the drug works less
evenly. As a result, some people may experience involuntary
movements (dyskinesia), especially when the medication is having its
peak effects. Waxing and waning of the response to the drug (wearing
off effects) also is common. This means that the time that each dose
is effective begins to decrease, leading to more frequent doses.
Other side effects may include hallucinations, a drop in blood
pressure especially when standing and nausea. Still, levodopa
often allows people with Parkinson's disease to extend the time
they're able to lead relatively normal lives and in many cases is
effective for a number of years.
Unlike levodopa, these drugs aren't changed into dopamine. Instead,
they mimic the effects of dopamine in the brain and cause neurons to
react as though sufficient amounts of dopamine were present.
Dopamine agonists are used both as adjuncts to levodopa therapy and
also initially in early Parkinson's disease, especially in younger
adults. The side effects of dopamine agonists are similar to those
of levodopa. This class of drugs includes the older dopamine
agonists, bromocriptine (Parlodel) and pergolide (Permax) and the
newer drugs, pramipexole (Mirapex) and ropinirole (Requip). Avoid
dopamine agonists if you already have experienced hallucinations or
One clinical trial
suggested that pramipexole may slow the progression of Parkinson's
disease. Whether this truly occurs remains uncertain, but some
physicians have chosen to begin early treatment with pramipexole
based on the results of this study. Another clinical trial showed
similar results for ropinirole, but these results remain somewhat
This drug, used as an adjunct to levodopa therapy, helps prevent the
breakdown of both naturally occurring dopamine and dopamine formed
from levodopa. It does this by inhibiting the activity of the enzyme
monoamine oxidase B (MAO-B) the enzyme that metabolizes dopamine
in the brain. At one time it was thought that this drug might slow
the progression of Parkinson's disease, but this now appears not to
be the case. Toxic reactions have occurred in some patients who took
selegiline with the narcotic drug, meperidine (Demerol, Pethadol).
A newer class of drugs, COMT inhibitors prolong the effect of
levodopa therapy by blocking an enzyme that breaks down dopamine in
the liver and other organs. Tolcapone (Tasmar) is a potent COMT
inhibitor that easily crosses the blood-brain barrier and in
clinical trials reduced the amount of levodopa needed by 25 percent.
But because Tasmar has been linked to liver damage and liver
failure, the drug is normally used only in people who aren't
responding to other therapies. Entacaopne is a COMT inhibitor that
shares some of the properties of tolcapone but doesn't cross into
the brain. It may help manage fluctuations in the response to
levodopa in people with Parkinson's disease.
These drugs were the main treatment for Parkinson's disease before
the introduction of levodopa. In general, they help control tremors
in the early stages of the disease. Even so, they're only mildly
beneficial and sometimes the benefits are offset by side effects
such as dry mouth, nausea, urine retention especially in men with
an enlarged prostate and severe constipation.
can also cause mental problems, including memory loss, confusion and
hallucinations. A number of anticholinergic drugs, such as
trihexyphenidyl (Artane) and benztropine (Cogentin), are available.
The antihistamine diphenhydramine (Benadryl and antidepressants such
as amitriptyline (Elavil) work much like anticholinergics and may be
used in older adults who can't tolerate anticholinergics themselves.
This antiviral drug may be prescribed for people in the latter
stages of Parkinson's disease, especially if they have problems with
involuntary movements induced by levodopa (dyskinesia). Side effects
include swollen ankles and a purple mottling of the skin.
If you're using
medications for Parkinson's disease, it's extremely important not to
stop taking them on your own. If you're troubled by side effects or
any other problems, talk to your doctor.
Surgical procedures were once commonly used to treat Parkinson's disease
but fell out of favor with the advent of levodopa and other drug
therapies. Now, surgical approaches are being re-evaluated. The
following procedures may be an option when symptoms can't be controlled
This procedure has been used for years to reduce tremor in people
with Parkinson's disease, although it's not generally helpful for
other aspects of parkinsonism. Thalamotomy involves the destruction
of small amounts of tissue in the thalamus a major brain center
for relaying messages and transmitting sensations. The surgery can
cause slurred speech and sometimes lack of coordination when
performed on both sides of the brain. For that reason, it's usually
done on only one side of the brain, with the benefits confined to
one side of the body.
There has been renewed interest in pallidotomy since improved
imaging techniques have allowed surgeons to pinpoint the areas to be
treated with greater precision. In this procedure, an electric
current is used to destroy a small amount of tissue in the pallidum
(globus pallidus), a part of the brain responsible for many symptoms
of Parkinson's disease. Pallidotomy may improve tremors, rigidity
and slowed movement by interrupting the neural pathway between the
globus pallidus and the thalamus. It's especially helpful in
countering the involuntary movements caused by drug therapy.
pallidotomy has been helpful for some aspects of Parkinson's disease
in certain people, it's not a cure, and in many cases benefits may
not last. In addition, the surgery carries a number of risks,
including slurred speech, disabling weakness and vision problems,
especially when performed on both sides of the body.
Movement problems, such as a tremor, associated with Parkinson's, are
primarily caused by inadequate levels of a chemical (dopamine) that
transmits messages from the substantia nigra to other parts.
In 1997 the FDA approved a new brain implant device that can help
control the disabling shaking and trembling caused by Parkinson's
disease. The deep brain stimulator consists of a pacemaker-like unit
implanted in the chest that transmits electric impulses through a
wire to tiny electrodes in the subthalamic nucleus a structure
located deep within the brain that controls many aspects of motor
function. The pulses appear to interrupt signals that may play a
role in causing tremors. Potential risks exist with the deep brain
stimulator, including infection caused by the wire connecting the
electrode to the stimulator and the need to perform minor surgery to
change the unit's battery. Nevertheless, simulation within the
subthalamic nucleus may markedly improve Parkinson's symptoms for
many people. The device can also be placed in the thalamus for
tremor control or the globus pallidus to produce effects similar to
Although researchers continue to work to develop new drug treatments for
Parkinson's disease, great interest also exists in finding a way to
replace the dopamine-producing cells in the substantia nigra. One
approach has been fetal cell transplantation a procedure in which
fetal cells are implanted into the brains of people with Parkinson's.
Unfortunately, one large study, published in the March 8, 2001, issue of
the New England Journal of Medicine, reported that as many as 15
percent of study participants receiving transplanted fetal cells later
developed severe involuntary movements (dyskenesias) as a result of too
In addition, the use of fetal cells raises a number of moral and ethical
issues that won't be easily resolved. The answer, many researchers
believe, is the use of embryonic stem cells.
Stem cells are the parent cells of all tissues in the body. To date,
researchers have been able to capture and culture undifferentiated human
stem cells in the laboratory. The hope is that researchers may one day
be able to direct these cells to become specific types of cells such
as dopamine-producing neurons that can be used to treat disease. Stem
cells used in research are derived from embryos that were produced in a
laboratory to treat infertility and are used only with the informed
consent of the donors.
Researchers are also investigating genes that code proteins responsible
for producing dopamine, drugs that block the action of glutamate an
amino acid that destroys nerve cells and the role of the antioxidant
coenzyme Q-10 in stopping the progression of Parkinson's disease.
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