Treatment options for Parkinson's disease

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Three types of drugs can help treat Parkinson’s disease:

• medications that increase dopamine levels in the brain
• drugs to manage tremor and other symptoms affecting body movement
• medication for depression and other non-motor symptoms

Most medications can manage symptoms effectively for 3–6 years. After this, a doctor may need to review the person’s treatment options.

Does Medicare cover treatment for Parkinson’s disease?

Increasing dopamine levels

The symptoms of Parkinson’s disease mainly result from low levels of dopamine in the brain. Dopamine is a chemical messenger or neurotransmitter.

Drugs for Parkinson’s disease aim to replenish dopamine levels or mimic its action. These are called dopaminergic drugs.

Dopaminergic medications can:

• reduce rigidity and muscle stiffness
• improve the speed of movement
• help with coordination
• lessen tremor

Taking dopamine will not help because it cannot enter the brain, but drugs that enable the brain to create dopamine can be beneficial.

Doctors may prescribe the following medications:

Levodopa

Levodopa is the main medication for Parkinson’s disease. Nerve cells in the brain absorb the drug and turn it into dopamine. However, it can have adverse effects, including nausea and vomiting.

Carbidopa-levodopa (Sinemet, Rytary, or Parcopa) contains both carbidopa and levodopa. Adding carbidopa can reduce the dose needed for levodopa by around 80%.

While nausea and vomiting can be side effects of carbidopa-levodopa, they will be less severe than with levodopa alone.

Examples of carbidopa-levodopa include:

• Sinemet
• Stalevo
• Rytary
• Parcopa

Other side effects of carbidopa-levodopa may include:

• loss of appetite
• reduced blood pressure
• confusion
• lightheadedness

In time, levodopa can also become less effective, or its effectiveness may fluctuate. The person might experience “off” times between doses when movement becomes more challenging. To manage this, a doctor may adjust the dose.

After 3–5 years of using levodopa or carbidopa-levodopa, some people develop uncontrolled, involuntary movements (dyskinesia). For this reason, a doctor will monitor the dose carefully over time. The medications may also increase the risk of mood changes and psychosis.

Levodopa does not address all the symptoms of Parkinson’s disease. A person may still experience problems with balance, speech, falling, swallowing, and memory. However, the Parkinson’s Foundation notes that it can dramatically improve a person’s quality of life.

Dopamine agonists

These drugs mimic the effects of dopamine in the brain. The neurons react to them as they would to dopamine.

Dopamine agonists have a lower risk of long-term complications than levodopa, and the adverse effects may be less severe.

However, depending on the drug, some side effects can occur, including:

• nausea
• fainting
• low blood pressure
• sleepiness
• dyskinesia
• constipation
• confusion

Examples of dopamine agonists for Parkinson’s disease include:

• ropinirole (Requip)
• pramipexole (Mirapex)
• rotigotine (Neupro skin patch)
• apomorphine (Apokyn subcutaneous injection)

Dopamine agonists may not be suitable for people with a history of cardiovascular disease, depression, or psychosis.

A doctor usually prescribes these medications in tablet form, but they are also available as an injection or a skin patch.

Monoamine oxidase-B inhibitors (MAO-B inhibitors)

MAO-B inhibitors are an alternative to levodopa. They block the effects of monoamine oxidase-B (MAO-B). MAO-B is an enzyme that destroys dopamine in the brain. Blocking it allows dopamine to last longer in the brain.

Examples include:

• selegiline (Eldepry, Zelapar)
• rasagiline (Azilect)
• safinamide (Xadago)

MAO-B inhibitors can have some side effects, including:

• lightheadedness
• mild nausea
• dry mouth
• constipation

MAO-B inhibitors can interact with other drugs, including antidepressants. A person should tell the prescribing doctor which medications they are already taking to prevent potentially serious interactions.

Catechol O-methyltransferase (COMT) inhibitors

This type of medication blocks COMT, an enzyme that breaks down levodopa. It has no impact if a person uses it alone, but it can help prolong the benefits of levodopa therapy.

It is available as:

• entacapone (Comtan)
• tolcapone (Tasmar)
• opicapone (Ongentys)

Stalevo combines carbidopa, levodopa, and entacapone in one drug.

Tremors and body movement

Amantadine

Originally created to treat the flu, amantadine (Gocovri) provides immediate relief for motor symptoms in most people with Parkinson’s disease.

Doctors do not know exactly how it works, but it seems to affect a number of receptors in the brain.

It is available as a 100 milligram capsule and also in liquid and tablet form. People with kidney problems may need to take a lower dose.

Side effects include:

• nausea
• a dry mouth
• sleep problems
• confusion and hallucinations
• lightheadedness
• fluid and urine retention

Anticholinergics

These medications control tremor. Examples include trihexyphenidyl (Artane) and benztropine (Cogentin).

However, some people prefer not to use these drugs because of the side effects, which can include:

• urine retention
• confusion and hallucinations
• dry mouth
• reduced short-term memory
• blurred vision

Two commonly prescribed anticholinergics are trihexyphenidyl (previously sold as Artane) and benztropine (Cogentin).

Depression, psychosis, and dementia

Depression affects up to 50% of people with Parkinson’s disease, according to the American Academy of Neurology (AAN), and up to 50% will also experience psychosis. Up to 30% will experience anxiety. Dementia and apathy are also common.

The table below shows some of the medications a doctor may prescribe to treat each of these conditions, according to the Parkinson’s Foundation.

Psychosis and other conditions can result directly from Parkinson’s disease, but they can also be adverse effects of other drugs.

A doctor may need to review the person’s medications to check for possible interactions or adjust the dose to reduce adverse effects.

Around 13.6% of people with Parkinson’s disease may have impulse control disorder, with symptoms such as uncontrolled spending. According to the Parkinson’s Foundation, the use of dopamine receptors as treatment may be the main cause.

Learn about Lewy body dementia, a type of dementia that may occur with Parkinson’s disease.

Parkinson’s disease can lead to slurred speech and difficulty swallowing. A speech and language therapist can provide muscle training techniques that may help overcome some of these problems.

An occupational therapist can help identify everyday tasks that can be challenging and work with the person to find practical solutions.

This may include new strategies for dressing, preparing meals, performing household chores, and shopping. Adaptations to the home environment can also make daily living easier.

For people with Parkinson’s disease, deep brain stimulation may help manage:

• tremor
• slow movement (bradykinesia)
• stiffness
• walking difficulties

This involves three parts:

• an electrode inside the part of the brain that controls movement
• a pacemaker-like device, or neurostimulator, under the skin in the upper chest
• a wire under the skin connecting the neurostimulator to the electrode

The neurostimulator sends electrical impulses along the wire and into the brain via the electrode. These impulses can prevent symptoms by interfering with the electrical signals that cause them.

There is a small risk of brain hemorrhage, infection, and headaches. Some people may see no improvement, or their symptoms may worsen. There may also be discomfort during stimulation.

Nevertheless, the AAN considers this treatment safe and effective for specific people and say any adverse effects are usually mild and reversible. Anyone considering this treatment should discuss the pros and cons with a healthcare professional.

A doctor will not usually recommend it for people who have had Parkinson’s disease for under 5 years. This is because it can take 5 years to confirm that symptoms are due to Parkinson’s.

These types of surgery involve destroying small parts of the brain responsible for some symptoms of Parkinson’s disease.

Destroying the thalamus may help relieve tremor. Destroying the pallidum may help reduce stiffness, rigidity, and involuntary movements.

The thalamotomy procedure involves:

• applying a local anesthetic
• making a small hole in the skull
• inserting a hollow tube
• using liquid nitrogen to destroy the thalamus

The surgeon may use ultrasound to guide the procedure.

A thalamotomy may help if a person has a severe tremor on one side, but it is only possible to do it on one side. If the tremor affects both sides, it may not help.

Many people with Parkinson’s disease experience fluctuations in blood pressure. Low blood pressure is common when standing up or after eating. High blood pressure may be a problem at night.

This may result from changes to the nervous system, but some medications can also worsen symptoms.

Medications can help raise blood pressure, but a person should watch for adverse effects, especially when lying down, as there may be a risk of blood pressure becoming too high.

Examples of drugs include:

• fludrocortisone (Florinef)
• midodrine (Proamatine)
• droxidopa (Northera)

Lifestyle tips that may also help include:

• taking time to change position
• increasing the intake of fluids, salts, and caffeine
• wearing support stockings during the day

Alternative therapies that may be beneficial include:

• tai chi
• acupuncture
• dance and music therapy
• massage

However, more research is necessary to confirm the effectiveness of most of these treatments.

Some people use supplements for Parkinson’s disease, but there is limited research to support their use.

Products and supplements that people use include:

• Coenzyme Q10: There is some limited evidence that taking this may help prevent disability from developing.
• Creatine: There is not enough evidence to show that this helps, and it may cause gastrointestinal symptoms.
• Velvet bean (Mucuna pruriens): The seeds of this plant contain levodopa, and there is some limited evidence that it may help.
• Vitamin E: This is unlikely to help, and high doses may have adverse effects.

A person should seek medical advice before using herbal remedies or supplements. Some products may interact with other medications or make symptoms worse.

There is no evidence that any specific diet will help people with Parkinson’s disease, but a healthful diet comprising plenty of fresh fruit and vegetables will enhance a person’s overall health.

It may also help prevent constipation and nutritional deficiencies.

Here, learn more about how dietary choices may affect people with Parkinson’s disease.

Some people experience weight loss. A dietitian can offer advice on how to prevent this.

Exercise

Physical therapy can help people manage their symptoms and feel better. A 2013 review reported that exercise improves gait, mobility, and balance in people with Parkinson’s disease.

Exactly how exercise can help a person with Parkinson’s is unclear, but animal studies suggest it may offer some neuroprotection.

Moderate activities, such as walking, gardening, and swimming, may be suitable. They may also enhance the person’s overall sense of well-being.

A doctor can help a person decide what kind of exercise may be beneficial. People should also be aware of the risk of falling when planning activities.

The symptoms and impact of Parkinson’s disease will vary between individuals. Scientists are still looking for a cure for Parkinson’s, but medication and other treatment can help manage symptoms and improve a person’s quality of life.

It can take time to get the treatment right, and symptoms can change over time. Staying in touch with the doctor is important for maintaining a suitable treatment regime.