Medications are tailored to the individual and will vary from person to person, as no two people with Parkinson's will experience the same symptoms with the same severity. Mild symptoms in Parkinson's may not need to be treated. A tremor that doesn't interfere with activities may be more tolerable than the potential side effects of medication. For younger people with mild to moderate symptoms in the early stages of Parkinson's, a carbidopa/levodopa-sparing strategy may be recommended. A person's age and presence of other problems may determine which medications should be used. As Parkinson's changes over time, additional medications may need to be added or increased.
The importance of integrative care; rehabilitation therapies and targeted exercise are especially important to enhance safety and quality of life in all stages of PD. We take a deep dive into the most common medication management strategies by topic below.
Constipation and Medications
Constipation can also play a significant role in carbidopa / levodopa absorption and ON-OFF fluctuations. In the digestive system, food makes its way from the mouth to the large intestine through the alimentary canal (esophagus, stomach, and small and large intestines). Sometimes your intestines aren't being emptied regularly. In that case, the carbidopa/levodopa you take won't make its way through the digestive system as it should, and therefore, it cannot control your symptoms most effectively. Staying regular means your carbidopa/levodopa will work most effectively, and you will experience less OFF time.
Managing Medication Side Effects
The most common side effects of PD medications are nausea and/or vomiting. These occur most often when first taking the drug and usually disappear over time. In addition to a queasy stomach, you may feel drowsy or experience low blood pressure or hallucinations.
The following are some tips to help control or relieve nausea:
Take the medication with a small carbohydrate snack, such as crackers or toast
Your doctor may add extra carbidopa to your medication
Drink liquids that are clear, cold, and contain sugar. These types of fluids often help calm the stomach better than others.
Avoid most fruit juices because they have a high acidity level that can make your nausea worse.
Eat and drink slowly.
Take your time eating and drinking. Smaller meals spread throughout the day and drinks consumed in between these meals may help reduce your nausea.
Eat bland foods (e.g., saltine crackers, bread, rice) and be sure to avoid greasy and sweet snacks.
Keep your food one temperature - if you are eating hot food, don't also include cold food. If you are feeling nauseated by the smell of hot or warm foods, try to eat foods that are either cold or at room temperature instead
Keep your head elevated after eating.
Reduce and avoid activity right after eating so as not to induce vomiting.
Do not brush your teeth directly after eating
If you often feel nauseous when you wake up in the morning, leave crackers on your bedside table and snack on them before you get up. You can also eat a high-protein snack before bed.
Medication Optimization
To reduce off times, you want to be able to get the most out of your medications. Here are a few tips you might try to increase the effectiveness of your medication:
Take the medication as prescribed by your doctor. Make sure you understand the expected benefit and potential early side effects of a drug before you leave the doctor's office. Remember that your doctor probably has more clinical experience in treating people with PD than anyone else who is likely to give you advice (especially if the physician is a Movement Disorder Specialist)
Do not increase or suddenly stop any of your drugs without checking with your doctor first.
Levodopa generally works best on an empty stomach, so aim to take your meds around a half hour before your meals, or at least an hour after. If your medication is causing you to feel nauseous, you may have to take it with food until your body adjusts.
Make sure you take your meds with four to five ounces of water so that the drugs are absorbed into your body quickly.
Timeliness
As Parkinson's advances, you may require many different forms of medication at different times. Being on time is especially important because a missed or delayed dose can quickly worsen mental and motor symptoms. Putting together a medication schedule can be extremely important and especially helpful when:
Someone other than the care partner who prompts and manages medication is not available - putting a copy on the fridge with a magnet or next to the medication
Traveling - keeping one available in your purse as a reminder to not get off schedule
Hospital Visits - along with the medication in case the hospital doesn't have it - having a print-out of the schedule can be extremely helpful to give to the ER, hospital staff, or nurses
Doctor Office Visits - Make sure you can hand this print-out off to the nurse to ensure records at your office are current and up to date - it can also speed up the appointment, leaving more time for discussion
To help you remember when to take your medication, many people use the "alarm" functions on their smart phones or watches if available. Alarms can prompt you to take your medication when you are in the middle of another task so that you can remember to take your medication on time.
Pill organizers and/or pill boxes are also very helpful to organize medications. Some even come with alarms and prompts. There are various sizes - so make sure you get one that accommodates the times of days you need to take your medications. Some people will dedicate one night a week to organize pills for the following week. There are even some organizers that allow you to organize your pills by the month.
Blister packs are also now available through many pharmacies where they will put your prescriptions in pre-sealed packets according to the doses. This can help organize your pills by dosage per pack, and they come with printed directions for administering. These are generally prepared by the pharmacy and each pack contains one day's worth of pills or pills to be taken at a certain time.
Find a system that works best for you, but always remember to take your medications on time, every time.
Managing PD Medications for ON Times
Tell your Doctor: Be sure to talk to your doctor about the "off time" episodes you're experiencing. Note if they occur at the same time (before your next dose of medication) or sporadically.
Adjust the timing: Your medication dosage or timing may be changed. Your doctor may change the amount of medication you're taking or the timing of the dose. Adjustments to the dosage or timing may reduce "off times."
Change the type of carbidopa/levodopa: The type of carbidopa/levodopa you're taking may be changed. Your doctor may change the form of therapy you're receiving. Some forms of carbidopa/levodopa are extended-release formulations that release the medication steadily for a longer period of time. There are also formulations that are available as a tablet that dissolves in your mouth or a suspension that is delivered directly into your small intestine via a tube.
Add another medication: Another medication may be added. Your doctor may add a different kind of medication to your current regimen.
Deep brain stimulation: Consider deep brain stimulation. Some people are good candidates for deep brain stimulation (DBS), a type of surgery in which a device is implanted in the brain to deliver electrical pulses and decrease the motor symptoms of PD. Ask your doctor if DBS is an option for you.
Consider your diet: Your diet may need adjusting. What you're eating and when, and how that coincides with your medication schedule, can impact the presence of "off times." Talk to your doctor and a nutritionist to determine if changing your diet can help manage your "off time."
Everyone is different: Each individual responds differently to the various treatments available for PD, and there is no one solution that works for everyone. In addition, your needs change as the disease progresses. By working with your doctor and telling him or her about the symptoms you're experiencing, including any "off time" you may be having, you can best manage your symptoms.
Medication Induced Parkinson’s Dyskinesia
Literally meaning "abnormal movement," dyskinesia is an uncontrolled, involuntary muscle movement that is irregular in motion. Although it can be a stand-alone condition, in people with PD it is most often associated with long-term use of carbidopa/levodopa or other Parkinson's medications that increase levels of dopamine in the brain. This type of carbidopa/levodopa-induced dyskinesia involves symptoms ranging from writing or wriggling to dramatic rocking and head bobbing. Severe dyskinesia, also referred to as troublesome dyskinesia, can significantly interfere with daily life and compromise gait and balance, limiting the person's engagement in activities such as running errands, participating in hobbies, meeting with family and friends, and eating in public.
If a person with PD is having dyskinesias that are bothersome or present most of the time, one option is to reduce the carbidopa/levodopa dose or other related PD medications. However, if doing so would adversely affect the control of your primary PD symptoms, your physician may prescribe treatment to specifically target the dyskinesia. An extended-release formulation of amantadine has been approved by the FDA specifically for the treatment of carbidopa/levodopa-induced dyskinesia in people with PD and has been demonstrated to also reduce OFF time. Another option is to consider other forms of amantadine, which are approved to treat Parkinson's - and may be prescribed off label to treat dyskinesia. For people with Parkinson's who are good candidates and willing to undergo surgery, deep brain stimulation (DBS) can be a successful treatment option for controlling Parkinson's dyskinesia.
Protein and Medications
The system that transports carbidopa/levodopa from the small intestine to the brain is the same system that transports amino acids. Both carbidopa/levodopa and amino acids must enter the bloodstream through the intestinal wall and then cross the blood-brain barrier to enter the brain. If too many amino acids are present along with carbidopa/levodopa, the medicine competes with the amino acids for absorption, and it won't enter the carrier system quickly.
Similarly, some amino acids compete with carbidopa/levodopa for absorption in their brain. Their presence at the time when carbidopa/levodopa makes its way to the blood-brain barrier will delay the time it takes for the brain to transform the medication to dopamine and, therefore decrease the medication's efficacy. This, too, can lead to delayed or only partial ON times.
In your stomach, protein is broken down into amino acids, which then travel to your small intestine. For your carbidopa/levodopa to work most effectively, it should enter your small intestine when few amino acids are present; this gives it easy access to the carrier system and fewer obstacles to crossing the blood-brain barrier. To maximize your ON times, avoid protein when you take your carbidopa/levodopa and talk to your physician about how dietary changes can help you get the most from your medications.
Water and Medications
To make its way from your mouth to your brain, carbidopa/levodopa must travel from your stomach to your small intestine, where it is absorbed by an extensive neutral amino acid active carrier system. A similar transport system transfers carbidopa/levodopa across the blood-brain barrier to the brain, where it is metabolized to produce dopamine. The more quickly the carbidopa/levodopa reaches the small intestine, the faster it passes through the intestinal walls and the brains' carrier system. The quicker it converts to dopamine, the more quickly you feel ON.
The key to minimizing delayed and partial ON times is to take your carbidopa/levodopa on an empty stomach with a full glass of water. The water "flushes" the medicine quickly to the small intestine, and the absence of food in your stomach means nothing can slow its emptying. (Crushing or chewing carbidopa/levodopa can also help speed the process, as can choosing a carbonated water beverage such as club soda or sparkling water.) Ideally, you would take each dose of your carbidopa/levodopa one hour before a meal (to give it time to move from the stomach to the small intestine) or two hours after (the amount of time it takes for food to empty the stomach.) Because this is not always possible, especially as your Parkinson's progresses and you take carbidopa/levodopa more often, aim to take each dose at least 30 minutes after a meal -- and, again, always with a tall glass of water.
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