While there is currently no cure for Parkinson’s there are a range of treatments which can help you manage your symptoms
Available treatments for Parkinson’s disease include a range of prescription medications, surgery and physical and supportive therapies. All treatments aim to control symptoms but none can yet prevent progression of the disease. Most medications have side effects. Which treatment is most suitable for an individual depends on factors such as the age of the person, the symptoms causing most distress and the severity and stage of their disease.
Sinemet® (levodopa/carbidopa) is a medication commonly used in the treatment of Parkinson’s disease as well as other neurological disorders. From 23 August 2018, there has been an international supply shortage of various formulations of Sinemet®.
Click here for a position statement providing an accurate, evidence-based guide for general clinicians to appropriately substitute the Sinemet formulation.
Click here for information on a temporary replacement for the standard formulation so Sinemet® that is available in Australia until end of August 2020.
NPS MedicineWise was established in 1998 as the National Prescribing Service (NPS) Limited. Through two decades of continuous national leadership and services provided in the health sector, NPS MedicineWise remains committed to supporting quality use of medicines to improve health decisions and health and economic outcomes in Australia.
Oral Medication is the first line of treatment for people living with Parkinson’s. Parkinson’s medication primarily works on increasing the levels of dopamine in the brain, and optimising the brain’s use of dopamine.
DOPAMINE REPLACEMENT THERAPY
Medications that can replace dopamine, the depleted neurotransmitter in the brain, are the mainstay of treatment. Levodopa, a precursor of dopamine, can be converted to dopamine in the brain. It is administered in combination with carbidopa (as in Sinemet and Kinson) or benserazide (as in Madopar), to maximise the delivery of levodopa to the brain and minimise side effects. These medications are usually effective for many years. However, the response tends to wear off or becomes less predictable with time.
Medications such as bromocriptine (Bromocriptine-BC, Bromohexal, Bromolactin, Kripton, Parlodel), pergolide (Permax), cabergoline (Cabaser) and apomorphine (Apomine) stimulate the dopamine receptors in the brain and therefore mimic the action of dopamine. They can be useful at all stages of Parkinson’s disease. In younger onset Parkinson’s disease agonists are sometimes used as initial treatment but in others agonists are prescribed as levodopa sparing agents or introduced once the response to levodopa starts to diminish.
This group of medications was the first available treatment for Parkinson’s disease before levodopa. They block the effect of acetylcholine, another brain chemical, to re-balance its levels with dopamine. They include benztropine (Cogentin, Benztrop), biperidine (Akineton) and benzhexol (Artane). Some antihistamines such as diphenhydramine (Unisom Sleepgels) also have anticholinergic activity and a useful sedative effect. All these drugs are now rarely used because of the relatively modest benefits that they give compared with their side effect profile.
This drug has both anticholinergic and dopamine agonist properties. It can be useful for many patients in controlling drug-induced involuntary movements (diskinesia).
MONAMINE OXIDASE (MAO) TYPE B INHIBITORS
Medications such as selegiline (Elderpryl, Selgene) and rasagiline (Azilect) prevent the breakdown of available dopamine within the brain and therefore prolong the action of levodopa.
Warning: This class of drug may have serious reactions if given in combination with Pethidine or certain types of antidepressants. Check with your health professional before taking any other medication if prescribed with the above drugs.
CATECHOL-O-METHYL TRANSFERASE (COMT) INHIBITORS
Newer medications such as entacapone (Comtan) and, in some cases, tolcapone (Tasmar), are also used along with levodopa. By blocking an enzyme known as COMT that breaks down levodopa in the intestine and brain, they prolong the action of levodopa and reduce motor fluctuations.
Deep brain stimulation (DBS)
Deep Brain Stimulation (DBS) Surgery for Parkinson’s
Deep Brain Stimulation (DBS) is the most common type of surgery used to treat Parkinson’s. It may help to reduce some motor symptoms of Parkinson’s, such as stiffness, tremor and slowness of movement.
DBS can help to control symptoms but it is not a cure.
Even after DBS surgery, Parkinson’s will continue to progress and medication will still be required.
DBS is not for everyone, and it does not always work for people who have had the operation.
It is essential to discuss your suitability for surgery with your treating neurologist and a DBS specialist neurologist. Only a DBS specialist can confirm your suitability for this procedure.
What DBS surgery involves
DBS surgery involves implanting electrodes – which are attached to leads – into specific sites in the brain. These sites are selected based on the specific symptoms that the surgery aims to address.
The electrodes are usually implanted under local anaesthetic so the patient will be awake. Once implanted, a small electrical current will be sent through the leads to the electrodes to test how the person’s symptoms respond to the stimulation.
When correct placement of the electrodes is confirmed, the attached leads are tunnelled under the skin from the skull down the neck and around to the chest or stomach are where a neurostimulator device will be placed.
A neurostimulator is similar to a pacemaker. Most are powered by a battery that lasts for 3 years or more before requiring replacement. Some models are powered by a rechargeable battery. In that case the person will be taught how to use a recharging unit.
Using the neurostimulator
The neurostimulator will be switched on once the wounds from surgery have healed. The electrodes will then deliver high-frequency stimulation to the area of the brain that is targeted.
This stimulation changes some of the electrical signals in the brain that cause the symptoms of Parkinson’s.
A specialist will program the stimulator using a small computer. The person will also be shown how use their own programming device to adjust stimulation and check battery life.
It may take several months to fully program the stimulator and adjust Parkinson’s medication to get the most benefit from this treatment.
What to expect following DBS surgery
After surgery people are usually asked to come back after 6 weeks, 3 months, 6 months and 12 months. This timing may vary depending on the type of procedure and individual situations.
It is important to attend all of your follow up appointments with your neurologist and neurosurgeon.
It is also important to pay attention to any behavioural, emotional or cognitive changes experienced after surgery.
If you have any concerns or begin to feel unwell, you must contact your specialist immediately.
Living with a DBS device
Most everyday activities are safe when you are living with a stimulator implanted in your body. However, avoid any activity where you may be exposed to strong electrical currents.
If in a situation where people are required to pass through a security scanner, advise the security officer that you have a pacemaker-like device installed.
Request a manual security check instead, because of the risk of the electromagnetic scanner affecting your stimulator.
It is also a good idea to carry the hand-held programmer when travelling. This is in case the stimulator is accidentally switched off. You will also be provided with a card to carry that explains you have had DBS surgery.
When in contact with doctors, hospital staff and other healthcare professionals –including dentists and physiotherapists – tell them a neurostimulator has been implanted.
This is important because following DBS surgery, medical brain scans can only be used under very strict conditions. Also, antibiotics have to be prescribed when there is a risk of germs getting into the blood stream – for example during dental procedures or surgery.
Procedures such as diathermy should not be used on someone who has had DBS surgery. Diathermy involves the use of a high frequency electronic current to produce heat and relax muscles.
Focused Ultrasound Therapy to treat tremor
Focused Ultrasound is used to treat Parkinson’s patients experiencing tremor that does not respond to medication.
In medical terms this procedure is known as a non-invasive thalamotomy.
During the Focused Ultrasound procedure, the patient is awake. No general anaesthesia or surgical incisions are required.
A frame is placed on the patient’s head with local anaesthetic and the patient lies in a Magnetic Resonance Imaging (MRI) scanner. If required some sedation can be given to help maximise comfort and relaxation during the procedure.
Doctors then use brain scans to direct ultrasound beams to the target location in the thalamus region of the brain.
The thalamus is a small structure within the brain located just above the brain stem. It has nerve connections with both cerebral cortex and the midbrain. The main function of the thalamus is to relay motor and sensory signals to the cerebral cortex.
The focused ultrasound sends 1024 individual ultrasound beams through the brain that intersect at a single target point in the thalamus to destroy the tremor-causing cells without damaging the surrounding normal tissue.
This is all monitored in real time on the MRI and by repeatedly checking the patient and until the tremor has been treated.
When the treatment is over there is an immediate and significant reduction in tremor.
In Australia, Focused Ultrasound therapy is administered by St Vincent’s Hospital where it is known as the Neuravive Procedure.
In addition to its value in treating tremor in Parkinson’s patients, this procedure shows enormous research potential in neuroscience. For example, it can temporarily open the blood-brain barrier (BBB) to improve the delivery of:
- Genes, growth factors, stem cells, and other neuroprotective and/or neurorestorative drugs
- Anti-alpha synuclein antibodies
PHYSICAL AND SUPPORTIVE THERAPIES
People with Parkinson’s disease should remain as active as possible, maintaining daily activities and, if possible, a regular exercise program. Support therapies from physiotherapists, occupational and speech therapists can also help with specific exercises, education and retraining to improve coordination, balance and movement. Overall fitness and good muscle tone can help minimise some of the abnormal movements associated with Parkinson’s disease.
The facts on medical cannabis for treating Parkinson’s
To date, no large-scale studies or peer reviewed scientific research have established the safety and effectiveness of medical cannabis for treating the symptoms of Parkinson’s.
There have been a small number of randomised controlled trials conducted but these studies were too small to be meaningful and inconsistent in their approach.
Parkinson’s NSW supports appropriate, ethical scientific research into the therapeutic benefits of medical cannabis. However, evidence of its safety and effectiveness is currently lacking.
Therefore, Parkinson’s NSW does not endorse the use of medical cannabis for the treatment of Parkinson’s.
We recommend that you do not rely on the internet, social media or word of mouth for information about medical cannabis.
If you are considering any form of unproven therapy, first talk to your GP and neurologist about the potential benefits, risks and costs involved.
Kluger B, Triolo P, Jones W, Jankovic J, The Therapeutic Potential of Cannabinoids for Movement Disorders, Movement Disorders Vol 30 No 3, 2015
Carroll CB, Bain PG, Teare BM, Lui X, Joint C, Wroath BA, Parkin SG, Fox P, Wright D, Hobart J, Zajicek JP, Cannabis for Dyskinesia in Parkinson Disease, Neurology October 2004
Stampanoni Bassi M, Sancesario A, Moreace R, Centonze D, Iezzi E, Cannabinoids in Parkinson’s Disease, Cannabis and Cannabinoid Research Vol 2.1 2017