Question

5. Briefly outline the rationale for reducing the dosage interval rather than

increasing the dosage.

6. The on/off syndrome and end-of-dose deterioration are both features of treated

Parkinson’s disease. What are they, and are there any risk factors?

7. In addition to levodopa therapy, what other options are available to treat Parkinson’s disease and what is their place in therapy?

8. Mr. DM is concerned that he is likely to forget the five times daily dosage regimen and/or find it difficult to maintain a regular dosage interval. Is there anything you could do to help him?

Answer 1

Parkinson's disease

A chronic neurological disorder affecting movement characterised by slowness of movement ( bradykinesia), tremors, postural instability and rigidity.

5. Doctors are prescribing more frequencies for drug intake rather than increasing the dosage of the drug is mainly due to the potential side effects of the drugs, if it is accumulated in the blood. With a minimum dose ,after it's half life the drug will get metabolized by the body systems,mainly kidney and liver.

In PD, overdose of the medications such as levodopa and carbidopa causes dizziness, headache ,nausea , vomiting, light headedness, trouble sleeping with unusual dreams etc. Cabodapa or levodopa has a half life of 60 to 90 minutes. Initial stage of PD the frequency of drug is less and the effect is more good , but as the disease progress ,more brain cells wil die and the dopamine will get depleted so fast and there will not be any reservation in the cells. Then the frequency of the dosage should be more , rather than increasing the dose.

6. On|/ off syndrome and end-of- dose deterioration

On / off syndrome experienced by the PD patients: on/ off fluctuations are the the motor fluctuations of PD patients, especially when on levodopa treatment. initially stages of treatment, the ' on ' stage is characterised with well control of motor symptoms and the person can function and move well. As the Levodopa losses it's effect on the brain, the symptoms gradually returns and the movements become difficult and the patient experience 'off ' . When the treatment progress the stage of effectiveness or the 'on' stage will be less and off stage will be more.

End of dose deterioration is the phenomenon that occurring in PD patients. The patient experiences the wearing off syndrome before 15 to 30 minutes of the next dose of drug especially levodopa. It is due to the deterioration of the previous dose drug's concentration in the brain ( dopamine concentrion. Patient may experience the difficulty in movement and involuntary movements.

Risk factors:

Non adherence to drug (Improper intake if drugs ), certain protein rich foods like meat , fish and cheese may delay gastric emptying and the absorption of tablets, stress , sleeplessness are the risk factors that may cause on/ off syndrome or End of dose deterioration.

7. Other options to treat PD

Other than the medications Levodopa and carbidopa,

Apomorphine : short acting FDA approved dopamine agonist.

Amantadine : drug for levodopa induced dyskinesia

Botulinum toxin A ( Botox): to reduce saliva production and to weaken overactive muscles

Other therapies:

Carbidopa- levidopa intestinal gel

Deep brain stimulation: to regulate abnormal brain cells activity

8.

* Educate the client regarding the importance of adherence to drug

* Instruct the patient to set an alarm for five times to remember about the drug time

* Automatic drug dispenser : This devise will be useful for the patient who are under treatment.Thus equipment can assist the patient for medication administration.

* Mobile apps: There are various applications that helps the patient to make remember him regarding the drug , dose and frequency.