Tuesday, August 30, 2011

PINOY PARKINSON'S DISEASE THRU GOD'S PEACE

Peace is the second fruit of the Holy Spirit. When Jesus died on the cross and was resurrected after 3 days, He made his appearance to the disciples.


 'On the evening of that first day of the week, when the doors were locked, where the disciples were, for fear of the Jews, Jesus came and stood in their midst and said to them, "Peace be with you." When he had said this, he showed them his hands and his side. The disciples rejoiced when they saw the Lord.[Jesus] said to them again, "Peace be with you. As the Father has sent me, so I send you." And when he said this, he breathed on them and said to them, "Receive the Holy Spirit..."'

                                                                                                     John 20:19-22


You stepped out of the doctor's clinic after having been diagnosed with Parkinson's Disease. You tell yourself: "It isn't true! How can it be? I'm still young and at the peak of my career." You're angry with everyone. You quarrel with your spouse. You yell at your kids. You become a monster in the eyes of your co-workers. You're like the INCREDIBLE HULK when angry but you can't move, become stiff, easily fall when someone cuts into your path and your hand trembles when it's not busy.
You begin to alienate yourself as your sickness progressed. Your wife ignores you. Your kids put you down. Your friends avoid your company while others stab you in the back. You have no hope for cure. But you can always count on God, the One being who can help you and heal you so you are more able to cope with your illness and make each day count with peace in your heart.


 "Have no anxiety at all, but in everything, by prayer and petition, with thanksgiving, make your request known to God. Then the peace of God that surpasses all understanding will guard your hearts and minds in Christ Jesus.
 Finally, brothers, whatever is true, whatever is honorable, whatever is just, whatever is pure, whatever is lovely, whatever is gracious, if there is any excellence and if there is anything worthy of praise, think about these things. Keep on doing what you have learned and received and heard  and seen in me. Then the God of peace will be with you."

                                                                                                         Philippians 4:6-9


 'Bless those who persecute [you], bless and do not curse them. Rejoice with those who rejoice, weep with those who weep. Have the same regard for another; do not be haughty but associate with the lowly; do not be wise in your estimation. Do not repay anyone evil for evil; be concerned for what is noble in the sight of all. If possible, on your part, live at peace with all. Beloved, do not look for revenge but leave room for wrath; for it is written, "vengeance is mine, I will repay, says the Lord." Rather, " if your enemy is hungry, feed him; if he is thirsty, give him something to drink; for by so doing, you will heap buring coals upon his head." Do  not be conquered by evil but conquer evil with good.
     
                                                                                                       Romans 12:14-21

Monday, August 29, 2011

PINOY PARKINSON'S DISEASE (PD) THRU GOD'S WISDOM

The first gift of the Holy Spirit is WISDOM. When the Lord asked King Solomon what he wanted to receive, here was his prayer:

Wisdom 9:4-6
 SOLOMON'S PRAYER

 "Give me Wisdom, the attendant at your throne, and reject me not from among your children; For I am your servant, the son of your handmaid, a man weak and short-lived and lacking in comprehension of judgment and of laws. Indeed, though one can be perfect among the sons of men, if Wisdom, who comes from you, be not with him, he shall be held in no esteem."
      
       

What is the value of wisdom?

 Proverbs 3:13, 16-24

 "Happy the man who finds wisdom, the man who gains understnading!...Long life is in her right hand, in her left are riches and honor; Her ways are pleasant ways, and all her paths are peace; She  is a tree of life to those who grasp her, and he is happy who holds her fast. The Lord by wisdom founded the earth, established the heavens by understanding; By his knowledge the depths break open, and the clouds drop down dew. My son, let not these slip out of your sight; keep advice and counsel in view'; So will they be life to your soul, and an adornment to your neck. Then you may securely go your way; your foot will never stumble; When you lie down, you need not be afraid, when you rest, your sleep will be sweet. "
         
How can you acquire wisdom?

 Proverbs 4:11-13, 18, 20-26

 "On the way of wisdom I direct you, I lead you on straightforward paths. When you walk, your step will not be impeded, and should you run, you will not stumble. Hold fast to instruction , never let her go; keep her for she is your life....But the path of the just is like shining light, that grows in brilliance in perfect day."
 "My son, to my words be attentive, to my sayings incline your ear; Let them not slip out of your sight, keep them within your heart; For they are life to those who find them, to man's whole being they are health. with closest custody, guard your heart, for in it are the sources of life. Put away  from you dishonest talk, deceitful speech  put far from you. Let your eyes look straight ahead and your glance directly forward. Survey the path for your feet, and let all your ways be sure. Turn neither to right nor to left, keep your foot far from evil."


   

       
         
Seeking wisdom from those who know will enable you to conquer your Parkinson's disease and believe that healing is possible through God. Hence, we have invited Michael Angelo Fetalvo Lobrin to be one of the resource speakers in PINOY PD THRU G-MEN.  Brother Michael Angelo, as he is fondly called, is a best selling author and widely sought-after inspirational speaker. His famous book "LAUGH WITH GOD TODAY" explained some verses in the Bible through an unconventional way. What better way to read and learn the Scriptures with humor.

Wednesday, August 24, 2011

PINOY PARKINSON'S DISEASE THRU GOD'S LOVE

Join me in this journey as we start the nine week countdown towards healing of Parkinson's disease. For the next nine weeks, I will present the fruits and the gifts of the Holy Spirit by quoting verses from the greatest book ever written, which is the Holy Bible.

 LOVE is the first fruit of the Holy Spirit. Loving God and allowing Him to fill up your love tank is the first step to obtain healing.

 Mark 12:30-31
 THE GREATEST COMMANDMENT.
 "You shall love the Lord your God with all your heart, with all your soul, with all your mind, and with all your strength.' The second is this: 'You shall love your neighbor as yourself.' There is no other commandment greater than these. "

 Romans 13:8-10
 LOVE FULFILLS THE LAW
 Owe nothing to anyone, except to love one another; for the one who loves another has fulfilled the law. The commnadments, "You shall not commit adultery; you shall not kill; you shall not steal; you shall not covet," and whatever other commandments there may be, are summed up in this saying, [namely]" You shall love your neighbor as yourself." Love does no evil to the neighbor; hence love is the fulfillment of the law."   


 Romans 12:9-12
 MUTUAL LOVE
 "Let love be sincere; hate what is evil, hold on to what is good.; love one another with mutual affection; anticipate one another in showing honor. Do not grow slack in zeal, be fervent in spirit, serve the Lord. Rejoice in hope, endure in affliction, persevere in prayer."

 Thus, we begin the series of Pinoy PD thru G-MEN with a prayer...


PRAYER FOR HEALING OF PARKINSON’S DISEASE THROUGH THE INTERCESSION OF BLESSED JOHN PAUL II

When my legs are frozen in place,
 May God the Father push me and remind me
 To lift my toes up and swing my arms
 That I may walk again and not be afraid.

When I feel like falling or as my posture stoops,
 May Jesus Christ, God the Son, break my fall
 And catch me as I move forward
 With my legs braced and feet wide apart.

When my movement is slow and I hesitate,
 May God the Holy Spirit enlighten my path,
 Broaden my horizon and show me the way
 That I will be more agile and sure in my steps and bearing.

 When my hands and feet are shaking, or my chin trembles,
 And my voice weakens as I speak,
 May Mother Mary embrace me to calm me and assure me
 That everything will be okay and I can rest in her arms and wait
 Until everything is still and steady and I am in peace
 As my voice grows strong and clear.

 Forgive me, God the Father, for all my sins
 Heal me, God the Son, from my Parkinson’s disease
 Bless me, God the Holy Spirit, with wisdom and knowledge
 Love me, Mother Mary, so that I can love and serve others despite my PD.
 We ask all these, through the intercession of Blessed John Paul II.
 Amen.
 Our Father…
 Hail Mary…
 Glory Be…

 Blessed John Paul II, Pray for us.
 St. Joseph, Pray for us.

Let me be like a child as I surrender
 and trust in the Lord and pray to my guardian angel…

 “Angel of God, my guardian dear,
 To whom God’s love commits me here.
 Ever this day be at my side
 To light and guard to rule and guide. Amen.”


PINOY PARKINSON'S DISEASE THRU G-MEN (GOD, MEDICINE, EXERCISE AND NUTRITION)


PINOY PD THRU G-MEN (GOD, MEDICINE, EXERCISE AND NUTRITION) will be the First Annual Convention for lay persons with Parkinson’s Disease (PD) and their caregivers which will be held on October 22, 2011. This date has been chosen for the convention because it coincides with the Feast Day of Blessed John Paul II who himself suffered from Parkinson’s disease but did not deter the late Pope from performing his anointing.




        We have gathered four resource speakers who will discuss the holistic approach in the management of Parkinson's Disease. One is a Neurologist and Movement Disorder Specialist who will tackle the updates in the diagnosis and medical management of PD.  Another is a Rehabilitation Medicine Specialist who will discuss the physical aspect in the therapy of PD. An author and expert will also give a lecture on vegetarianism and meditation. While the fourth speaker is a prolific and sought-after inspirational speaker.



        There will also be three simultaneous workshops which will showcase the Complementary and Alternative Medicine (CAM) in the treatment of Parkinson's disease. Each of these workshops will be open to the participants with limited slots only.


        For the next nine weeks, you will come to know PINOY PD THRU G-MEN and what it stands for. This will be our vehicle to spread the good news that there is still hope for every PD regardless of race, sex or creed. Parkinson's disease may not have a cure but it should not put an end to the life of anyone afflicted with it because it will open doors so others may learn to share every thought, every word and every deed with LOVE in their hearts for PD.

For more information:
Visit website: www.pinoyparkinsonsdisease.blogspot.com

GOOD NUTRITION IN PARKINSON'S DISEASE

Good nutrition is important for everyone and has a significant role in the management of Parkinson’s
disease (PD). In general, a healthy diet can increase energy, optimize the effect of medications, and
promote overall well-being, especially in a patient with PD.


Patients with PD may experience constipation, delayed stomach emptying,drug-nutrient interactions, and weight loss. Parkinson's disease affects the autonomic nervous system, resulting in slowed movement of the GI tract. An individual may experience constipation and/or delayed gastric emptying. Gastric emptying may delay or decrease effectiveness of medications. With adequate intake of fluids and fiber, constipation may be prevented. Signs and symptoms of delayed gastric emptying should be observed when determining the timing of meals and medications.


Some individuals, particularly those who experience fluctuations of PD symptoms with their
medications, may be very sensitive to the amount of protein in their diets. For these individuals, the
timing of medications and meals/snacks containing protein becomes important. With the right amount of  protein consumed at the proper intervals throughout the day, that is 30-60 minutes after medications, both optimal absorption of medications and protein needs are met.


Parkinson’s disease symptoms such as tremor and the medication side-effect of dyskinesia may increase one’s caloric needs. When caloric needs are not met, the individual may experience unintentional weight loss and even malnutrition in instances of continuous low calorie intake. Adequate intake of vitamins and minerals is also important for many bodily functions. Each individual’s diet varies greatly, so you should first consult your doctor or dietitian before taking any supplements.


Eating a well-balanced, nutritious diet will greatly benefit a patient with Parkinson's disease so he
can have more energy and his medications will work properly. There are ten basic tips of having a
proper diet, namely:
1. Eat a variety of foods from each food category based on the food pyramid (see below).
2. Ask your doctor if there is a need for a daily vitamin supplement.
3. Maintain your weight through a proper balance of exercise and food.
4. Ask your doctor about your ideal body weight and how many calories you should consume each day.
5. Include high-fiber foods such as vegetables, cooked dried peas and beans (legumes), whole-grain
foods, bran, cereals, pasta, rice, and fresh fruit in your diet.
6. Choose foods low in saturated fat and cholesterol.
7. Moderate your intake of sugars.
8. Limit your salt intake.
9. Drink eight 8 oz. glasses of water per day.
10. Ask your doctor about drinking alcoholic beverages since alcohol may interfere with some of your medications.




CARBOHYDRATES


Carbohydrates are starches and sugars which are the main energy source for the body. One gram of
carbohydrates provides 4 calories. These are found in fruits, breads and cereals, milk products, and
vegetables. These are also found in most desserts, candy, and sweetened foods.
The“good” carbohydrates are the complex carbohydrates which are found in foods that are less refined and closer to their natural state. Good sources include foods made with whole grains, brown rice, and fresh fruits and vegetables. These are usually good sources of vitamins, minerals, and fiber, too. These are broken down slowly in the digestive tract, and gradually enter the bloodstream.
Dietary carbohydrates play a role in the absorption of levodopa, the usual first line drug  used in
PD, by triggering a release of insulin which lowers the blood levels of large neutral amino acids
(LNAA's).  Lower levels of  LNAA's in the blood may enhance the delivery of levodopa to the brain . The recommended allowance for carbohyrates is 55 to 60 percent of the calories in your diet.


PROTEINS


Proteins are combinations of amino acids that build, repair, and maintain all of your body’s tissues.
Dietary proteins are broken down into amino acids in the stomach and intestine and then absorbed into the blood, where they become the “building blocks” for new proteins. Your body makes nonessential amino acids. The “essential” amino acids are not synthesized in the body so these are obtained through the diet. To get the necessary amino acids, it is important to eat a variety of foods, including good sources of protein in amounts to meet your needs. If you don’t consume enough carbohydrates and fats, tissue proteins can be broken down into amino acids and used by the body for energy instead of maintenance. When you consume more protein than you need, the protein is broken down and stored as body fat. Protein provides 4 calories per gram.
Good sources of protein include foods from animal and plant sources. Animal sources include meat,
poultry, fish, eggs, milk, and cheese. Plant sources include legumes (lentils, dry beans and peas),
seeds, nuts, breads, and cereals.


FATS


Fats are complex substances made up of combinations of fatty acids which supply energy in the form of calories. They are a concentrated source of energy, providing 9 calories per gram.  Fats have some
positive health benefits although they are best avoided or kept at a minimum in certain disease
conditions like hypertension, obesity and heart ailments.  These help to support the work of other
nutrients in your body. The fat-soluble vitamins A, D, E and K wouldn’t be effective without dietary
fats to dissolve them and provide transport in the bloodstream.


Linoleic acid and alpha-linolenic acid are fatty acids (the “building blocks” of fat) that are
considered essential because they are not synthesized in the body and have to be obtained from the
diet. Alpha-linolenic acid converts to omega-3 fatty acids, which help to keep your brain and nervous
system healthy. Linoleic acid is an omega-6 fatty acid. Both may promote heart health by lowering
total and LDL cholesterol.Both of these essential fatty acids are easily available to the body in a
varied diet. Fatty fish, soy, flaxseed, canola, nuts, and seeds are good sources of omega-3 fatty
acids. Soy, corn, and safflower oil are good sources of omega-6 fatty acids.


Fat intake should be no more than 30 percent of your total calories, with an emphasis on fewer
saturated fats. Fat takes longer to leave the stomach than carbohydrate or protein; therefore, it’s
best to avoid large, high-fat meals if you’re taking Sinemet because it can decrease the effectiveness
of the medication by delaying gastric emptying.


FIBER


Fiber is the indigestible part of a food of plant origin. It can’t be used by the body for energy, but
is still necessary for good health by helping to promote regular bowel movements. Dietary fiber can be soluble or insoluble. Both types of fiber have significant health benefits, but they work in different
ways.


Insoluble fiber helps to prevent constipation by adding bulk and softness to stools. Adequate fluid
intake is necessary, since insoluble fiber works by absorbing fluid. Good sources of insoluble fiber
are whole wheat products including wheat bran, vegetables, fruit, flaxseeds, and legumes.


Soluble fiber helps to lower blood cholesterol levels, and regulate blood sugars. Good sources of
soluble fiber are legumes, oats and oat bran, barley, flaxseeds, and many fruits and vegetables.


Constipation is a common problem in Parkinson’s disease. It can be caused by medications, decreased fluid intake, or the condition itself. The nerves controlling the gastrointestinal tract can be
affected by PD, causing increased intestinal content transit time. Dietary fiber is very important in
the management of constipation. To ensure adequate fiber intake, try to eat at least five servings of
fruits and vegetables each day, and choose whole grains over refined foods. In addition, try to drink
6 to 8 glasses of fluid each day, preferably noncaffeinated.


VITAMINS


Vitamins are organic compounds necessary for life, although they do not, independently, provide
energy. Vitamins are essential to many bodily functions, including growth, metabolism, blood clotting, preventing diseases, body growth and maintenance, immune function, and many more.


Vitamin D


Vitamin D promotes the absorption of two minerals - calcium and phosphorus - and regulates the calcium levels in the blood. It also helps in depositing these minerals in your bones and teeth, making them stronger. Fortified foods such as milk and specially fortified orange juice are common sources of Vitamin D. Milk products such as cheese and ice cream are generally not fortified with Vitamin D.
Sunshine is a significant source of Vitamin D because your body makes Vitamin D from UV light touching your skin.


The RDA for adults is 400 IU per day, and 600 IU by the age of 70. The increased amount for older
adults is due to the fact that as we age, our skin isn’t able to produce as much Vitamin D. If you do
not go outdoors, you cover up, or use a sunscreen, you need to pay special attention to getting
Vitamin D from fortified foods or consider taking a supplement. One cup of Vitamin D fortified milk
contains 100 IU.


Vitamin C & E


Vitamin C, or ascorbic acid, and Vitamin E have antioxidant properties and were once speculated to be protective against the progression of PD. Theoretically, free radicals are produced by metabolic
processes in the brain and they can damage nerve cells, including dopaminogenic cells. Antioxidants
are known to break down free radicals or prevent their formation. Studies, however, do not show any
significant benefit of consuming more than the recommended dietary allowance (RDA) for Vitamin C and E for people with PD.


Vitamin C is important for wound healing, absorption of iron, increasing resistance to infection, and
the synthesis of neurotransmitters. Good sources of Vitamin C are citrus fruits, broccoli, brussel
sprouts, green peppers, strawberries, cauliflower, cabbage, tomato, cantaloupe, and spinach. The RDA for Vitamin C for an adult is 60mg per day. This is equal to approximately 1/2 cup of orange juice or 1 cup of cantaloupe.


Along with its powerful antioxidant capabilities, Vitamin E is also important in energy and cell
metabolism. The RDA for Vitamin E for adult males is 10mg and 8mg for females. This is equal to
approximately 1.5 oz. almonds or 3 tablespoons of corn oil. Other good sources of Vitamin E are
vegetable oils, wheat germ, spinach, collards, nuts, and dried beans.


Both Vitamin C and E are easily consumed in the diet in the recommended amounts per day; therefore, supplementation in mega doses is not warranted. Depending on your individual diet, a multi-vitamin formulation or supplement may be beneficial. Please consult your doctor or dietitian for further information.


MINERALS


Minerals are inorganic substances essential to life. Theses help regulate the various body processes
such as circulation, respiration, digestion, and elimination. These are also found in water and in
natural foods but are used to fortify some processed foods.


Mineral toxicity is possible but unlikely if you are not taking megadoses of a mineral over a period
of time. Mineral deficiencies are also possible but not common if you are eating a wide variety of
foods from all five food groups.


CALCIUM


Calcium builds bones, and helps them to remain strong, by slowing the rate of bone loss as you age. It also assists in muscle contraction, promotes normal nerve function, and helps your blood clot if you’re bleeding. Milk and milk products such as yogurt and cheese are excellent sources of calcium. In addition, some dark green leafy vegetables (kale, broccoli, bok choy), canned salmon and sardines with bones, calcium-fortified soy milk and orange juice, and tofu made with calcium sulfate are good
sources.


The RDA for adults is 800 IU until age 50, when it is increased to 1200 IU. People with Parkinson’s
disease have an increased risk of bone loss, and should be sure their diet isn’t deficient in calcium.
If you find it hard to get enough calcium in your diet, you may want to consider a supplement. Calcium carbonate is the most commonly used supplement; however, it reduces stomach acid, which can interfere with nutrient absorption. It can also be constipating for some people. Calcium citrate is a better choice; it doesn’t affect stomach acidity, and it isn’t constipating.


Excellent sources of calcium:
(approximately 300mg per serving)
1 cup of low fat milk
1 cup of yogurt
1 1/2 ounce of hard cheese
1 1/4 cup cottage cheese
1 to 2 cups of cooked dark green, leafy vegetables
2 cups of cooked broccoli


IRON


Iron forms part of hemoglobin, the molecule that enables your red blood cells to transport oxygen
throughout the body. It also helps the immune and central nervous systems and aids in energy
production.


The body is very efficient at storing and reusing iron, and stored levels tend to increase with age;
however, iron deficiency can be a problem for younger women because of blood loss from menstruation and for older people because of a poor diet. A suspected deficiency should always be evaluated by your healthcare provider before taking supplements because excess iron can be harmful. The RDA for iron for adult women is 10 mg and 15 mg for adult men. Meat, poultry, and fish are excellent sources of iron. Fortified grain products, like cereals and breads, legumes (especially soybeans), nuts, and vegetables also provide iron in the diet. Foods that are high in Vitamin C, such as strawberries, broccoli, or citrus fruits, enhance iron absorption.


Iron supplements can interfere with Levodopa absorption, so they should be taken separately, although the small amount of iron in a standard multivitamin preparation shouldn’t be a problem.


COENZYME  Q10


Coenzyme Q10, or ubiquinone, or CoQ10 for short, is a naturally occurring compound produced in the heart, liver, kidneys, and pancreas. CoQ10 is used by the body for energy production and as a powerful antioxidant. The amount of CoQ10 produced by the body declines with age, heart disease, and with some medications i.e., statins, some diabetes drugs, and perhaps coumadin.
CoQ10 is present in food in small amounts, primarily in organ meat, chicken, beef, soy oil, sardines,
mackerel, and peanuts. Because CoQ10 is in food only in scarce amounts, it is commonly consumed as an oral supplement.


Oral CoQ10 supplementation has been used to treat heart failure because of its role in energy
production. It may also be beneficial in treating a number of other diseases as well as Parkinson’s
disease due to its antioxidant effects. A theory is that it protects cells from damage caused by PD.
Research suggests a positive trend for CoQ10 and the slowing of the progression of the disease with
little side effects. Recent studies have shown that a dose of 1,200 mg per day may have the most
benefit in PD patients; however, CoQ10 recommendations are premature at this time and further research is warranted. Please consult your doctor beforehand.


PARKINSON'S MEDICATIONS AND FOOD INTERACTIONS


The primary drug used in the treatment of Parkinson’s disease is Levodopa. There are several diet
components that interfere with the absorption and thus, ultimately, with the effectiveness of this
medication.


   PROTEIN AND LEVODOPA INTERACTION


Compounds called amino acids make up dietary protein. Levodopa is structurally similar to certain
amino acids (large neutral amino acids, or LNAAs), and they compete for the same transport system
across the blood-brain barrier. Levodopa must arrive at its destination in the brain to be converted
to dopamine, and this competition can decrease the amount of Levodopa reaching the brain. Some people with Parkinson’s disease are not affected by protein in the diet, but others notice a reduced
effectiveness of Levodopa when it is taken too close to meals. Also, some people find that the
proteins in milk and milk products block the Levodopa absorption to a greater extent than other
proteins.


     GASTRIC EMPTYING


Before it can reach the transport mechanism at the blood-brain barrier, Levodopa must reach the small intestine for absorption. Food in the stomach can slow the progress of the Levodopa by delaying the emptying of stomach contents into the small intestine. The longer Levodopa remains in the stomach, the more vulnerable it is to enzymes that prematurely convert it to dopamine, which is ineffective if not produced in the brain. Once in the small intestine, the Levodopa must compete with any LNAAs present for absorption into the bloodstream. Also, Levodopa has a very short plasma half-life, which means that it will start to disappear from the blood in 60 to 90 minutes. Therefore, it needs to reach the brain before this occurs.


Parkinson’s disease can affect the nerves of the GI tract causing delayed gastric emptying. If you
experience symptoms of bloating, delayed uptake of medications, quick fulfillment after eating,or
gastroesophageal reflux, consult your doctor or dietitian for helpful hints and/or medication changes.


     TIMING OF MEDICATION


Levodopa should be taken at least 30 minutes prior to meals, except in cases where the drug produces
nausea, or if there is an excess of dyskinesia after taking Levodopa. It generally works best when
taken on an empty stomach, about ½ hour before meals or at least one hour after meals. It should be
taken with 4-5 oz. of water so the drug will be absorbed in the body more quickly.
For some patients, levodopa may cause nausea when taken on an empty stomach. Your doctor may prescribe a combination of levodopa and carbidopa (called Sinemet) or carbidopa by itself (called Lodosyn). If nausea persists, your doctor may prescribe another drug to relieve these symptoms. There might also be a need to modify your daily protein intake. In rare cases, a diet high in protein limits the effectiveness of levodopa. For nausea, which is common during the early adjustment to Levodopa, it should be taken with a light, low-protein snack.


There are ways to contol nausea, namely:
1. Drink clear or ice-cold drinks. Drinks containing sugar may calm the stomach better than other
liquids.
2. Avoid orange and grapefruit juices because these are too acidic and may worsen nausea.
3. Drink beverages slowly.
4. Drink liquids between meals instead of during meals.
5. Eat light, bland foods (such as saltine crackers or plain bread).
6. Avoid fried, greasy, or sweet foods.
7. Eat slowly.
8. Eat smaller, more frequent meals throughout the day.
9. Do not mix hot and cold foods.
10. Eat foods that are cold or at room temperature to avoid getting nauseated from the smell of hot or
warm foods.
11. Rest after eating, keeping your head elevated. Activity may worsen nausea and may lead to
vomiting.
12. Avoid brushing your teeth after eating.
13. If you feel nauseated when you wake up in the morning, eat some crackers before getting out of bed
or eat a high protein snack before going to bed (lean meat or cheese).
14. Try to eat when you feel less nauseated.


Some Parkinson's disease medications may make you thirsty. Here are eight tips to help relieve thirst
or dry mouth:
1. Drink eight or more glasses of liquid each day. However, those PD patients with concommittant heart
problems may need to limit their fluids so it is better to seek advice from your doctor.
2. Limit caffeine (contained in coffee, tea, cola, and chocolate) because it may interfere with some
of your medications and may actually make you more dehydrated.
3. Dunk or moisten breads, toast, cookies, or crackers in milk, decaffeinated tea or coffee to soften
them.
4. Take a drink after each bite of food to moisten your mouth and to help you swallow.
5. Add sauces to foods to make them soft and moist. Try gravy, broth, sauce, or melted butter.
6. Eat sour candy or fruit ice to help increase saliva and moisten your mouth.
7. Don't use a commercial mouthwash. Commercial mouthwashes often contain alcohol that can dry your mouth. Ask your doctor or dentist about alternative mouthwash products.
8. Ask your doctor about artificial saliva products which may be available by prescription.


Sometimes, a PD patient may be too tired to eat later in the day or has poor appetite. Here are some
tips to help improve your appetite and make each meal enjoyable:
1. Choose foods that are easy to prepare and eat.
2. Ask your family/caregiver to help with meal preparations.
3. Keep healthy snack foods on hand such as fresh fruit and vegetables, pretzels, crackers, high-fiber
cold cereals.
4. Freeze extra portions of what you cook so you have a quick meal when you're too tired.
5. Rest before eating so you can enjoy your meal.
6. Try eating your main meal early in the day so you have enough energy to last you for the day.
7. Consult your doctor especially when you're showing signs of depression aside from poor appetite.
Your appetite will probably improve after depression is treated.
8. Avoid non-nutritious beverages.
9. Eat small, frequent meals and snacks.
10. Walk or participate in another light activity to stimulate your appetite.
11. Make eating a pleasurable experience by using colorful place settings and play background music
during meals.
12. Try not to eat alone. Invite a guest to share your meal or go out to dinner.
13. Use colorful garnishes such as parsley and red or yellow peppers to make food look more appealing
and appetizing


Here are some tips to help you eat more at meals and at snacks.
1. Drink beverages after a meal instead of before or during a meal so that you do not feel full before
you begin eating.
2. Plan meals to include your favorite foods.
3. Try eating the high-calorie foods in your meal first.
4. Use your imagination to increase the variety of food you're eating.
5. Don't waste your energy eating foods that provide little or no nutritional value such as potato
chips, candy bars, colas, and other snack foods.
6. Choose high-protein and high-calorie snacks. High calorie snacks include: ice cream, cookies,
pudding, cheese, granola bars, custard, sandwiches, nachos with cheese, eggs, crackers with peanut
butter, bagels with peanut butter or cream cheese, cereal with half and half, fruit or vegetables with
dips, yogurt with granola, popcorn with margarine and parmesan cheese, or bread sticks with cheese
sauce.


WEIGHT MAINTENANCE IN PARKINSON'S DISEASE


Malnutrition and weight maintenance is often an issue for people with Parkinson's disease. Here are
some tips to help you maintain a healthy weight:
1. Weigh yourself once or twice a week, unless your doctor recommends weighing yourself more often. If you are taking diuretics or steroids, such as prednisone, you should weigh yourself daily.
2. If you have an unexplained weight gain or loss (2 pounds in one day or 5 pounds in one week),
contact your doctor. He or she may want to modify your food or fluid intake to help manage your
condition.
3. Ask your doctor about nutritional supplements. Sometimes supplements in the form of snacks, drinks (such as Ensure or Boost), or vitamins may be prescribed to eat between meals to help you increase your calories and get the right amount of nutrients every day. But, be sure to check with your doctor before making any dietary changes or before adding supplements to your diet. Some can be harmful or interfere with your medication.
4. If you are underweight, avoid low-fat or low-calorie products. (unless other dietary guidelines
have been recommended). Use whole milk, whole milk cheese, and yogurt.



REFERENCES:


1. http://www.webmd.com/parkinsons-disease/guide/eating-right
 2. Jenny E. Loew, MS, RD, CSN, LDN and Carol Pratt , LDN. Good Nutrition and Parkinson's Disease (American Parkinson Disease Association, Inc)Copyright 2005 Revised 2007

Tuesday, August 9, 2011

THE ROLE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE IN PARKINSON'S DISEASE


Does complementary and alternative medicine play a role in the treatment of Parkinson’s disease? How do we define “Complementary Medicine”? What is “Alternative Medicine”? How does each of these two terms differ from the “Conventional Medicine” in the treatment of PD?

The study of medicine in the present times has evolved into an integrative approach which considers the need to stimulate the body’s natural healing process. It includes the use of conventional therapy as well as complementary and alternative medicine especially in those disease conditions with no cure or progressive in its course, including those that can be prevented or retarded.

Conventional medicine is defined as the “standard of care” for a particular condition, either because the treatment has been studied scientifically and found to be safe and effective, or because there is consensus that the treatment works.
On the other hand, complementary medicine refers to interventions used in conjunction with conventional medicine. One example of a complementary therapy is the use of acupuncture which now plays a role in pain management of some cancer patients in addition to the use of analgesics.

Whereas alternative medicine pertains to the use of practices that replaces those utilized in conventional medicine. An example is the use of a special diet to treat cancer in place of the use of conventional methods of intervention like surgery, radiation, or chemotherapy as recommended by a doctor.
In the treatment of Parkinson’s disease, “Conventional treatment” refers to the use of a pharmacological agent like Carbidopa/levodopa which has been extensively studied and is routinely used by physicians since it has been found to be efficacious. A “complementary therapy” is use of yoga in addition to the carbidopa/levodopa. An example of alternative therapy is use of herbal medicines instead of carbidopa/levodopa or another first-line medication.

What are the benefits of Complementary and Alternative Medicine?
One of the benefits in using CAM in PD would be the additional information a patient acquires as to the proper diet, exercise, and stress management in coping with his illness. CAM also addresses some of the secondary symptoms of PD such as constipation or fatigue which can be just as troubling, or even more troubling, than the motor symptoms. For some patients, it might also minimize the amount of medication they take in order to delay possible long-term side effects like dyskinesia (involuntary movements).

What are the different types of CAM?
A. Biologically Based Therapies
1. Orthomolecular and megavitamin therapy involve the adjustment of concentrations of molecules normally present in the body (e.g., vitamins, minerals, amino acids, hormones, and metabolic intermediates) for the prevention and treatment of disease. Coenzyme Q 10 and omega-3fatty acid-rich fish oils are examples of supplements in this category used by patients with PD.
2. Phytomedicine is often called herbal or botanical medicine and refers to the therapeutic ingestion of plants. This practice dates back at least 5000 years and has been used by all races, religions, and cultures throughout the world.

B. Energy Medicine
Reiki is a Japanese-derived healing modality in which a healing effect is induced by “life force” energy wherever the patient needs it most. The Reiki practitioner lightly applies hands on a clothed patient and channels healing energy as a general or localized treatment.
C. Manipulative and Body-Based Practices
1. Aromatherapy uses the aromatic oils of plants to improve and maintain well-being. More than three hundred different oils are produced from flowers, leaves, stems, and roots. The action of aromatherapy depends on the link between smell and memories. Massage and penetration of the oils into the body may also have a direct effect.
2. Electric stimulation involves the application of mild electric shocks to the skin. Chiropractors, massage therapists, and other practitioners of body work use this therapy to help relieve pain.
3. Massage therapy is a common therapeutic treatment where manual rubbing, stroking, tapping, and kneading the body (either a particular area or the whole body) is performed for the purpose of treating physical and emotional disorders, increasing blood flow, reducing pain, promoting relaxation, releasing muscle tension, and enhancing general health and well-being.

D. Mind-Body Medicine

1. Biofeedback involves the use of instrumentation to monitor, amplify, and report physiologic data for therapeutic purposes. The main objective of biofeedback is to change or regulate a physical process for better health, such as lowering one’s heart rate with controlled breathing and guided visualization.
2. Relaxation techniques can be helpful in reducing stress levels and include techniques such as progressive muscle relaxation and diaphragmatic breathing. More advanced techniques include hypnosis, guided imagery, and meditation.

E. Whole Medical Systems
1. Ayurveda is Sanskrit for “life knowledge,” and it is one of the oldest known systems of healing. Ayurveda approaches health as the balance of body, mind, emotion, and spirit. Treatments include yoga, meditation, purification regimens, dietary changes, and herbal remedies.
2. Oriental Medicine is an ancient system of diagnosis and treatment that corrects imbalances in Qi, or vital energy, with acupuncture, herbs, massage, nutrition, and movement. Acupuncture uses fine needles gently inserted at specific points along energy pathways of the body to encourage healing. Acupressure and low level laser acupuncture are non-invasive methods also aimed to balance one’s Qi.

3. Naturopathy is an alternative health system which emphasizes the body’s ability to heal itself. Therapies include the use of natural foods and supplements, massage, hydrotherapy, homeopathy, and exercise that supports self-healing. Practitioners of naturopathy generally prefer to use treatment approaches they consider the most natural and least invasive instead of using drugs or surgery.

How to Find the Right CAM Professional

As a general rule, it is prudent to avoid professionals who claim to provide a “cure” for Parkinson’s disease and be wary of those who charge exorbitant fees or ask for a big payment even before services are being offered or products are being delivered.  Every PD patient or his family or caregiver should also observe due diligence in verifying the authenticity, experience and expertise of the CAM professional especially those who advocate sudden withdrawal of prescription drugs for Parkinson’s without a thorough, accurate explanation. Despite the presence of information or studies on this drastic measure, it is best to consult with a neurologist or primary care physician for an opinion, or seek the advice of an integrative medicine physician.

How to Evaluate the Safety and Usefulness of CAM Therapies
A number of complementary and alternative modalities have been adopted by some PD patients and their families despite the absence of reliable studies or definitive proof like massage or Tai chi. However, the more invasive or experimental techniques or procedures should be supported by strong evidence before they are utilized.

It is to the best interest of every PD patient if a center can be put up which will fund research, provide grants to train researchers, and share its findings about CAM therapies with medical professionals and the public through information dissemination via lecture series, continuing medical education programs, and publication databases.

Alternative medicine that may be beneficial to a PD patient should also be evaluated for the possibility of doing more harm than good, especially with the “natural” means which does not always equate with “safe”.  Sometimes, it may take a considerable amount of time and effort before a CAM treatment can be found effective. The CAM therapies coupled with conventional medicine therapies should increase the potential benefits of both treatments. This should be discussed with the neurologist or primary care physician especially when using supplements or herbs since some can interfere with conventional drug treatments.
PD patients who are the most well-informed and have a balanced and realistic view of what conventional medications and alternative therapies can currently provide and who are aware of the limitations and side effects of such are those that are the most successful in coping with their illness. They usually treat CAM therapies with open-minded scepticism and accept that traditional medicines are sometimes necessary. Conventional therapies with CAM will help reduce or delay the effects of Parkinson’s and will arm the PD patient the tools necessary to combat his illness provided that they are properly guided by the medical professional.


REFERENCE:
Young Parkinson's Handbook
A Guide for Patients and Their Families

Wednesday, August 3, 2011

SURGICAL TREATMENT OF PARKINSON’S DISEASE


The first line of treatment of Parkinson’s disease is still medical. Most clinical studies as to the efficacy of pharmacological agents are based on the context of having mild, moderate and advanced disease. Thus, surgical treatment of PD has been reserved only for patients with both severe motor impairment from PD and motor complications in the form of fluctuations and dyskinesias.



In a review of literature of all researches done worldwide from 2001 to 2004, the following surgical interventions have been undertaken, namely:



1. Unilateral Pallidotomy

2. Pallidal Stimulation

3. Thalatomy

4. Thalamic Stimulation

5. Subthalatomy

6. Subthalamic Nucleus Stimulation (STN)

7. Human fetal mesencephalic transplantation

8. Fetal porcine cell transplantation



Of the above surgical procedures, unilateral pallidotomy and subthalamic nucleus stimulation (STN) have been found to be efficacious for symptomatic control of parkinsonism. However, only the former, i.e., unilateral pallidotomy, has been shown to be likely efficacious in the treatment of motor complications like dyskinesias and fluctuations. Thus, they are said to be clinically useful in the treatment of PD but with associated risk which are acceptable under specialized monitoring.

Pallidal stimulation has been observed to be likely efficacious for the symptomatic control of parkinsonism. It might possibly be useful for clinical practice but also with acceptable risk with specialized monitoring.

Human fetal mesencephalic transplantation has been observed to be non-efficacious in the symptomatic control of parkinsonism as well as in the treatment of motor complications. It also has an unacceptable risk of developing severely disabling dyskinesias predominantly affecting the legs which occurred generally 6 – 12 months after surgery thus requiring another surgical intervention.

The rest of the surgical procedures are still in the investigational stages and with insufficient data as to merit any clinical usefulness.



References:



Vitek JL, Bakay RAE, Freeman A, et al. Randomized trial of

pallidotomy versus medical therapy for Parkinson’s disease. Ann

Neurol 2003;53:558 –569.



Katayama Y, Kasai M, Oshima H, et al. Subthalamic nucleus

stimulation for Parkinson’s disease: benefits observed in levodopa intolerant

patients. J Neurosurg 2001;95:213–221



Olanow CW, Goetz CG, Kordower JH, et al. A double-blind

controlled trial of bilateral fetal nigral transplantation in Parkinson’s

disease. Ann Neurol 2003;54:403– 414.

Monday, August 1, 2011

MEDICAL TREATMENT OF PARKINSON'S DISEASE

Although it is a known fact the Parkinson’s disease has no cure, through the years, there have been various recommendations in the treatment of PD.  Some studies show promising results but others have unacceptable side effects, complications and even no therapeutic value. Thus, an international task force of the Movement Disorder Society conducted a systematic review of all articles and clinical reports published until September 2009 which has been the basis for the 2010 update.

An evidenced based scientific explanation is still the most reliable and acceptable standard for patient care. However, the physician is still expected to exercise his own clinical judgment as to the best treatment options for a PD patient based on the latter’s perception of his own impairment and disability

In the early stages of uncomplicated Parkinson’s disease, use of pharmacological agents is still the primary mode of treatment. The different drugs used in the therapy of PD will be discussed based on the mechanism of action (MOA), symptomatic treatment (monotherapy), adjunctive therapy, prevention of motor complications, symptomatic treatment of non-motor problems and safety.

These are the different pharmacological agents available in the market, namely:

     1. LEVODOPA

     2. ANTICHOLINERGICS

     3. AMANTADINE

     4. MAO-B INHIBITORS

     5. COMT INHIBITORS

     6. DOPAMINE AGONISTS



LEVODOPA

     Levodopa is the most effective treatment to improve the motor symptoms during the initial stages of PD. It is available in 2 formulations, namely (1) standard and (2) controlled-release (CR).

             Mechanism of Action:

           The standard levodopa formulation exerts its symptomatic benefits through conversion to dopamine, and is routinely administered in combination with a decarboxylase inhibitor (benserazide, carbidopa) to prevent its peripheral conversion to dopamine with the resultant nausea and vomiting. Levodopa passes the blood – brain barrier – in contrast to dopamine. It has a short half -   life, which eventually results in short - duration responses with a wearing - off (end- of- dose) effect. Controlled - release (CR) formulations aim to prolong the effect of a single dose of levodopa, and reduce the number of daily doses.
    
            Symptomatic Treatment of Parkinsonism ( monotherapy):

            The effiacy of levodopa is firmly established from more than 30 years of use in clinical practice. Sytematic reviews show that levodopa monotherapy, in general, produced lower UPDRS (Unified Parkinson’s Disease Rating Scale) scores than cabergoline, pramipexole, ropinirole, bromocriptine, lisuride, and pergolide. Standard and CR levodopa maintain a similar level of control in de novo PD after 5 years and also in more advanced PD with a duration of about 10 years and without motor fluctuations.

          Adjunctive Therapy:

            Supplementation of levodopa to other antiparkinsonian medications in stable PD is common clinical practice to improve symptomatic control.

            Prevention of Motor Complications:

            The motor complications like fluctuations and dyskinesia are actually caused by levodopa. Usually, levodopa is started three times daily, which offers symptomatic control throughout the day, but after several months or years of chronic treatment, these motor complications may arise. However, by   carefully shortening the dose interval to compensate for shortening of the duration of effect of each levodopa dose (wearing - off), and by reducing the dose of each levodopa intake to reduce the magnitude of the effect (peak dose dyskinesia), the clinical emergence of these motor problems may be  postponed. CR levodopa has no significant preventive effect on the incidence of motor fluctuations or dyskinesia, as compared with standard levodopa.

            Symptomatic Treatment of Non-motor Problems:

            Off - period psychiatric symptoms (anxiety, panic attacks, depression) and other non - motor symptoms (drenching sweats, pain, fatigue, and akathisia) may be alleviated by modifying the treatment schedule of levodopa.

            Safety:

            Peripheral side effects of levodopa include gastrointestinal and cardiovascular dysfunction. Central adverse effects include levodopa motor problems such as fluctuations, dyskinesia, and dystonia, and psychiatric side effects such as confusion, hallucinations, and sleep disorders. There is a 40 %  likelihood of developing motor fluctuations and dyskinesias after 4 – 6 years of levodopa therapy and up to 80-90% in later years. Neuropsychiatric complications occur in less than 5% of de novo patients on levodopa monotherapy.

ANTICHOLINERGICS (Bornaprine, Benzhexol, Benzotropine, Biperiden)

            Mechanism of Action:

            Anticholinergics are believed to act by correcting the disequilibrium between striatal dopamine and acetylcholine neurotransmission. Some anticholinergics, e.g. benzotropine, can also block dopamine uptake in central dopaminergic neurons. The anticholinergics used to treat PD specifically block muscarinic receptors.

            Symptomatic Treatment of Parkinsonism (monotherapy):

            The results are consistent with reviews concluding that anticholinergics have only a small effect on PD symptoms, and that evidence for a special effect on tremor is inconclusive.

            Adjunctive Therapy:

            The two reviews indicate that adjunctive anticholinergics have only a minor effect on PD symptoms in patients on levodopa therapy, and that the tremor - specific data are inconclusive.

            Prevention of Motor Complications:

            No studies are available.

            Symptomatic Treatment of Non- motor Problems:

            Because of the risk of side effects, centrally acting anticholinergics are usually not advised for the therapy of non - motor, i.e. autonomic, dysfunctions.

            Safety:

            The clinical use of anticholinergics has been limited by their side- effect profiles and contraindications. The most commonly reported side effects are blurred vision,urinary retention, nausea, constipation (rarely leading to paralytic ileus), and dry mouth. The incidence of reduced sweating, particularly in those patients on neuroleptics, can lead to fatal heat stroke.           Anticholinergics are contraindicatedin patients with narrow-angle glaucoma, tachycardia, hypertrophy of the prostate, gastrointestinal obstruction, and   megacolon. Impaired mental function (mainly immediate memory and  memory acquisition) and acute confusional state are a well documented central side effect that resolves after drug withdrawal. Therefore, if dementia is present, the use of anticholinergics is contraindicated. The abrupt withdrawal of anticholinergics may lead to a rebound effect with marked deterioration of parkinsonism. Consequently, anticholinergics should be discontinued gradually and with caution.

AMANTADINE

            Mechanism of Action:

            The mechanism of action of amantadine appears to be multiple. A blockade of NMDA glutamate receptors and an anticholinergic effect are proposed, whereas other evidence suggests an amphetamine - like action to release presynaptic dopamine stores.

            Symptomatic Treatment of Parkinsonism (monotherapy):

            Some studies and reviews show that amantadine induces symptomaticimprovement.

             Adjunctive Therapy:

            The addition of amantadine to anticholinergic agents is superior to placebo,  with the improvement more pronounced in severely affected patients. Over 9 weeks, amantadine was beneficial as an adjunctive treatment to levodopa with a more noticeable improvement in patients on low levodopa doses .Together with the results of low class evidence studies, data suggest that amantadine is probably effective as adjunct therapy, with an unproven long - term duration of effect.

            Prevention of Motor Complications:

            No studies available.

            Symptomatic Treatment of Non- motor Problems:

            Not applicable.

            Safety:

            Side effects are generally mild, most frequently including dizziness, anxiety, impaired coordination and insomnia ( > 5%), nausea and vomiting (5-10%), peripheral distal edema (unresponsive to diuretics), and headache, nightmares, ataxia, confusion/agitation, drowsiness, constipation/diarrhoea, anorexia, xerostomia, and livedo reticularis ( < 5%). Less common side effects include psychosis, abnormal thinking, amnesia, slurred speech, hyperkinesia, epileptic seizures (rarely, and at higher doses), hypertension, urinary retention, decreased libido, dyspnea, rash, and orthostatic hypotension (during chronic administration).

MAO-B INHIBITORS (Selegiline and Rasagiline)

            Mechanism of Action:

            Selegiline and rasagiline inhibit the action of monoamine oxidase isoenzyme type B (MAO - B). MAO - B inhibition prevents the breakdown of dopamine, producing greater dopamine availability. Mechanisms besides MAO-B inhibition may also contribute to the clinical effects. Unlike selegiline,      rasagiline is not metabolized to amphetamine, and has no sympathomimetic activity.

            Symptomatic Treatment of Parkinsonism (monotherapy):

            Five of six studies with a typical follow-up period of 3 - 12 months and a meta-analysis showed a small symptomatic effect of selegiline monotherapy. Two large scale placebo - controlled trials with rasagiline monotherapy in early PD with a follow-up of 6 – 9 months demonstrated consistent and significant results for a modest symptomatic benefit of early use of 1 mg and 2 mg/daily to early de novo PD patients.

            Adjunctive Therapy:

            The addition of selegiline to other antiparkinsonian therapies (mainly levodopa), showed no consistent beneficial effect on the core symptoms of PD in non-fluctuating patients. Rasagiline has not been studied in this context.

            Prevention of Motor Complications:

            Selegiline has shown no effect in preventing motor fluctuations including   wearing- off, ON– OFF fluctuations, and dyskinesia. Rasagiline has not been  studied in this context.

            Symptomatic Treatment of Non-motor Problems:

            A study detected no effect of selegiline on depression in PD. MAO - B inhibitors have not been investigated for the treatment of other non-motor problems.

            Safety:

            Like any dopaminergic drug, MAO - B inhibitors can induce a variety of dopaminergic adverse reactions. At the daily doses of selegiline currently recommended, the risk of tyramine - induced hypertension (the ‘ cheese effect ’ ) is low. The tyramine - effect does not need to be taken into          consideration when using rasagiline. Concerns that the selegiline/levodopa combination increased mortality rates have been allayed.

COMT INHIBITORS (Entacapone and Tolcapone)
    
            Mechanism of action:

            Catechol- O - methyltransferase (COMT) inhibitors reduce the metabolism of levodopa, extending its plasma half - life and prolonging the action of each   levodopa dose. Therapeutic dose of entacapone only acts peripherally and does not alter cerebral COMT activity. It is administered together with each dose of levodopa and is not approved for use in early (uncomplicated) and non- fluctuating PD patients. Tolcapone (a second-line drug) also acts peripherally but with a small central effect. Due to its stronger and longer action, tolcapone is recommended to be taken three times a day. Tolcapone is also not approved for use in early (uncomplicated) and non-fluctuating PD patients.

            Symptomatic Treatment of Parkinsonism (monotherapy):

            Not applicable (COMT inhibitors should always be given with levodopa).

            Adjunctive Therapy:

            All trials showed a small benefit in the control of the symptoms of parkinsonism, mostly reflected in the activities of daily living but the results  were not consistent. In two recent trials, levodopa/cerbidopa/entacapone showed only borderline significance when compared to levodopa/carbidopa alone in patients with no or minimal fluctuations. In a 39 - week, randomized,         double - blind, multicentre study, the efficacy, safety, and tolerability of  levodopa/carbidopa/entacapone (LCE, Stalevo ® ) was compared with levodopa/carbidopa (LC, Sinemet IR) in patients with early, de novo PD with note of a significant difference in the motor experiences of daily living and motor examinations combined.
           
            Prevention of Motor Complications:

            When the initiation of treatment with levodopa/carbidopa/entacapone was compared to that with levodopa/carbidopa, no difference was found  between the two treatment arms as to the prevention of motor fluctuations and dyskinesia.

            Symptomatic Treatment of Non-motor Problems:

            No studies available.
    
            Safety:

            COMT inhibitors increase levodopa bioavailability, so they can increase the incidence of dopaminergic adverse reactions, including nausea, and cardiovascular and neuropsychiatric complications. Diarrhea and urine discoloration are the most frequently reported non-dopaminergic adverse reactions. The combination with selective MAO-B inhibitors (selegiline) is allowed if the dose of MAO-B inhibitor does not exceed the recommended dose.

DOPAMINE AGONISTS

            Mechanism of Action:

            Of the ten dopamine agonists available in the market for treatment of PD,  five are ergot derivatives (bromocriptine, cabergoline, dihydroergocryptine, lisuride, and pergolide) and five are non-ergot derivatives (apomorphine, piribedil, pramipexole, ropinirole, and rotigotine).
            It is generally accepted that the shared D 2 - like receptor agonistic activity produces the symptomatic antiparkinsonian effect. This D 2 effect also explains peripheral (gastrointestinal – nausea and vomiting), cardiovascular (orthostatic hypotension), and neuropsychiatric (somnolence, psychosis, and hallucinations) side effects. In addition, dopamine agonists have other properties (e.g. anti - apoptotic effect) that have prompted their testing as putative neuroprotective agents. Apart from apomorphine or rotigotine, which are used via the subcutaneous (penject and pumps) or transdermal   (patch) routes respectively , all dopamine agonists are used orally. A once - daily controlled – release formulation of ropinirole has recently became available ,while one such formulation for pramipexole is currently under development .

            Symptomatic Treatment of Parkinsonism ( monotherapy):

            Based on some studies on dopamine agonists vs, placebo in the treatment of early PD, the following are found effective: dihydroergocryptine, pergolide, pramipexole, ropinirole, piribedil, and rotigotine; whereas bromocriptine and cabergoline are probably effective while lisuride is possibly effective.
            However, on studies on dopamine agonists vs. levodopa, it has been found that levodopa is more efficacious than any orally active dopamine agonist monotherapy. The number of patients able to remain on agonist monotherapy falls progressively over time after 5 years of treatment as in the          case of using any of these: bromocriptine, cabergoline, pergolide, pramipexole, and ropinirole.  After a few years of treatment, most patients who initially use a dopamine agonist monotherapy will receive levodopa as a replacement or adjunct treatment to control motor Parkinsonian signs. Over the past decade, a commonly tested strategy has been to start with an   agonist and to add levodopa later if worsening of symptoms cannot be controlled with the agonist alone. However, previously, it was common practice to combine an agonist like bromocriptine or lisuride with levodopa within the first months of treatment ( ‘ early combination strategy ’ ).

            Adjunctive Therapy:

            Most agonists have been shown to be effective in improving the cardinal    motor signs of parkinsonism in patients already treated with levodopa such as: apomorphine, bromocriptine, cabergoline, pergolide, piribedil, pramipexole, and ropinirole.

            Prevention of motor complications:

            Early use of an agonist can reduce the incidence of motor complications versus levodopa which has been observed in the studies on cabergoline, pramipexole, pergolide, ropinirole and bromocriptine. The risk of dyskinesia reappears once levodopa is adjunct to initial agonist monotherapy.

            Symptomatic Treatment of Non- motor Problems:

            Dopamine agonists like pramipexole may improve depression, as observed in clinical trials conducted in non – parkinsonian subjects with major or bipolar depression. 

            Safety:

            Dopamine agonists and all other active dopamine - mimetic medications share a common safety profile reflecting dopamine stimulation. Side effects such as nausea, vomiting, orthostatic hypotension, confusion, psychosis, and somnolence may occur with administration of any of these  agents. Peripheral leg edema, hallucinations and somnolence are more frequent with some  agonists than with levodopa, even in healthy subjects, in the case of somnolence. A recent meta – analysis suggested that while frequencies of somnolence, hallucination, or anxiety cases were higher with non - ergot DAs, incidence of vomiting, arterial hypotension, or depression was higher with   ergots. The rare but severe risks of pleuropulmonary/retroperitoneal fibrosis and valvular heart disorders are greater with ergot agonists than with non- ergot agonists. As pergolide and cabergoline have been the most frequently reported drugs at the present time, they are only used as a second - line alternative option, when other agonists have not provided an adequate response. If employed, regular monitoring of heart valves by ultrasound is mandatory.
            Impulse - control disorders have recently been identified as a common adverse drug reaction to dopamine agonists with prevalence rates ranging from 5-15% depending on the author. The principal risk factor is treatment with dopamine agonists, although they can occur on levodopa as well. Other risk factors    implicated are personal traits, disturbed decision-making abilities, younger age, comorbidities, cognitive impairment, disease severity, and polytherapy.