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


Main side effects


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


Nausea and vomiting Dizziness, fatigue Psychiatric disturbances Pleuropulmonary changes

Levodopa + carbidopa


Levodopa + benserazide

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



Apomorphine (SC injection)





Sleep disturbances

Dry mouth Nausea

Dizziness, fatigue




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

Motor problem


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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