Advanced disease

• Apomorphine can be used for severe akinesia not responsive to levodopa: apomorphine 600 •g to 6 mg (mean 3.4 mg) SC

• For nausea and vomiting side effects: domperidone 20 mg (o) tds

• Better control may also be achieved with: amantadine 100 mg (o) bd

Fig. 29.3 Micrographia, one of the signs of Parkinson's disease

Table 29.5 Anti-parkinson drugs

Agent

Main side effects

Amantadine

Nausea and vomiting Ankle oedema Livedo reticularis

Anticholinergic agents

• benztropine

Dryness of mouth Confusion in elderly

Contraindicated in glaucoma and prostatism Other anticholinergic effects, e.g. constipation

• orphenadrine

• procyclidine

Bromocriptine

Nausea and vomiting Dizziness, fatigue Psychiatric disturbances Pleuropulmonary changes

Levodopa + carbidopa

Levodopa

Levodopa + benserazide

Nausea and vomiting Involuntary dyskinetic movements Psychiatric disturbances On-off phenomena End of dose failure

Pergolide

Selegiline

Apomorphine (SC injection)

Nausea

Hypotension

Confusion

Dyskinesia

Sleep disturbances

Dry mouth Nausea

Dizziness, fatigue

Nausea

Psychosis

Dyskinesia

Table 29.6 Management of motor problems in treated Parkinson's disease 7

Motor problem

Management

End of dose failure

'On-off phenomenon

Loss of efficacy

Peak dose dyskinesia

Early morning dystonia

Nocturnal akinesia

• Dosages closer together

• Slow-release preparations

• Dopaminergic agonist, e.g. pergolide

• Subcutaneous apomorphine for 'off phase (1 hour action) with domperidone (o) to prevent vomiting

• Levodopa and ascorbic acid solution

• Increase levodopa dose as high as possible

• Dopaminergic agonist, e.g. pergolide

• Decrease levodopa dose

• MAO-B inhibitor, if efficacy lost

• Dopaminergic agonist, e.g. pergolide

• Slow release levodopa

• Dopaminergic agonists, e.g. pergolide

• Slow release levodopa

• Dopaminergic agonist

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