Medications for Non-Motor Symptoms
Non-motor symptoms are a collection of symptoms that are associated with Parkinson's, but are not components of the typically more widely-recognized (and disease-defining) motor symptoms. They can affect nearly any body system, arise at any time in the course of disease (even before motor symptoms or diagnosis occur) and differ in severity from person to person. Non-motor symptoms include constipation, low blood pressure, cognitive (memory and/or thinking) changes, mood and sleep disturbances, and many others. A number of therapies are available for the management of non-motor symptoms in Parkinson's. Some of these drugs are specifically approved for use in people with PD but the majority, although they are FDA-approved, don't have an indication for use in PD because they haven't been studied in large numbers of people with Parkinson's. Still, they are commonly prescribed in Parkinson's and often are beneficial. Here we give an overview of the treatments for many non-motor symptoms associated with Parkinson's.
Dietary and lifestyle modifications typically are the first step in the treatment of constipation. If these are not enough, over-the-counter medications may be recommended or prescription drugs might be provided. These could include:
- Fiber supplements, such as Metamucil (psyllium),
- Stool softeners, including Colace (docusate) and Miralax (polyethylene glycol),
- Laxatives, like Dulcolax (bisacodyl) and Milk of Magnesia, and
Those available over the counter should be used only with a physician's guidance. When constipation is especially significant, other medications for constipation (but not specifically indicated for use in people with Parkinson's) may be prescribed off-label.
Parkinson's disease dementia (PDD) is an impairment of memory and/or thinking significant enough to interfere with daily, social or occupational activities. Exelon (rivastigmine) is a medication that is FDA-approved for treating mild to moderate levels of PDD. It works to block an enzyme that breaks down acetylcholine, a chemical that supports memory and thinking abilities. Other medications that work in the same manner (but that are indicated for Alzheimer's dementia) -- such as Aricept (donepezil) or Razadyne (galantamine) -- may be used instead of Exelon in some Parkinson's patients.
These drugs can improve memory and thinking abilities and lessen behavioral changes (agitation or aggression, for example) that are associated with dementia. They also may delay the need for alternate living situations, such as nursing homes. Exelon is available as a pill, oral solution or skin patch.
Cons and Complications
The most common side effects of these drugs are nausea, vomiting, diarrhea, decreased appetite and weight loss. In some people, they also may worsen tremor.
Several different classes of antidepressant and anti-anxiety medications are prescribed for people with Parkinson's who experience mood disturbances. Some of the most commonly used drugs work on the serotonin and/or norepinephrine brain chemical pathways -- these are called selective serotonin reuptake inhibitors (SSRIs) or selective serotonin-norepinephrine reuptake inhibitors (SNRIs), respectively. Paxil (paroxetine) is an example of the former and Effexor XR (venlafaxine XR) the latter. In a trial called SAD-PD, these two medications were tested in people with Parkinson's and found to improve depression without worsening motor symptoms. Other medication types that might be used to treat depression include tricyclic antidepressants, such as Elavil (amitriptyline). However, these generally have more side effects than SSRIs or SNRIs.
For significant spells of anxiety or panic attacks, benzodiazepines -- such as Xanax (alprazolam) or Klonopin (clonazepam) -- may be prescribed to use as needed. These have to be used cautiously, though, as they can cause confusion, sleepiness and imbalance.
Because people with Parkinson's swallow less often, drooling may present an embarrassing or otherwise bothersome problem. In this case, drugs -- such as Robinul (glycopyrrolate), Artane (trihexyphenidyl) or even tricyclic antidepressants like Elavil (amitriptyline) may be prescribed to decrease saliva production. Possible medication side effects include constipation, confusion and sleepiness. Salivary gland Botox or Myobloc (botulinum toxin) injections are an alternate option.
Fatigue is difficult to treat with medication. Management most often focuses on lifestyle and behavioral adjustments, such as short naps in the early afternoon and regular exercise. Factors contributing to fatigue, such as sleep disorders, depression or other medical conditions, should be excluded prior to initiating medication management. If pharmacological treatment is necessary, stimulants -- such as Ritalin (methylphenidate) -- or wakefulness-promoting agents, such as Provigil (modafanil), may be used. Sometimes amantadine (Symmetrel) and MAO-B inhibitors (rasagiline or selegiline), which are used to treat PD motor symptoms, also can decrease daytime fatigue.
Orthostatic hypotension is a decrease in blood pressure upon changing positions, such as standing from sitting. It can be due to Parkinson's disease itself and/or the medications used to treat it and can cause dizziness, lightheadedness, passing out. It might even worsen walking or balance problems. When non-pharmacological treatments (dietary and behavioral changes) are insufficient, medication may be necessary. Northera (droxidopa) -- which is converted to norepinephrine (a body chemical that naturally raises blood pressure) -- is FDA-approved for orthostatic hypotension in PD. In some situations, medications that have different ways of raising blood pressure, such as Florinef (fludrocortisone) or ProAmatine (midodrine), may be prescribed instead.
Drugs for orthostatic hypotension can lessen dizziness and lightheadedness. They also may prevent passing out and/or falls resulting from imbalance or instability caused by low blood pressure.
Cons and Complications
Medications that raise blood pressure could cause high blood pressure while sitting or lying down, which is known as supine hypertension. Blood pressure should therefore be measured when sitting and lying down prior to and after starting medication, as well as any time dosages are adjusted. If nighttime blood pressure is elevated, raising the head of the bed and/or taking medication to lower blood pressure during sleep may be necessary. Additional potential adverse effects of Northera are headache, dizziness and nausea. Florinef might cause leg swelling and decreased potassium levels, so electrolyte levels need to be monitored.
Pain in Parkinson's can be due to a variety of factors -- the underlying disease itself, muscle pain due to dystonia or slowness, or injury from falls resulting from walking problems or imbalance. Conditions other than Parkinson's, such as arthritis or lower back pain, also may contribute to pain. Management of pain in Parkinson's may include addressing motor symptoms, treating injuries, or targeting non-motor symptoms like depression. When motor symptoms are the main contributing factor, adjusting Parkinson's medications is typically the first step. If general muscle pain or stiffness is the problem, over-the-counter analgesics, such as Tylenol (acetaminophen) or anti-inflammatories (such as Ibuprofen), may be used. Pain due to Parkinson's disease itself can manifest in many ways (radiating, tingling, aching, etc.) and may be treated with medications used for pain syndromes. Some examples include anticonvulsants, such as Neurontin (gabapentin) or Lyrica (pregabalin), or antidepressants, such as Elavil (amitriptyline). All medications, including over-the-counter ones, have potential side effects which should be discussed with your physician. When pain is particularly severe, a doctor who specializes in pain management may be consulted.
The main symptoms of Parkinson's disease psychosis are visual hallucinations -- seeing things that aren't there -- and delusions -- firmly held, false, often paranoid, beliefs. These may arise throughout the course of Parkinson's but are more common in later stages and in association with dementia or significant cognitive impairment. If psychosis threatens safety or impacts a person's or their caregiver's quality of life, an antipsychotic drug may be necessary. Nuplazid (pimavanserin) is an FDA-approved drug that works on the brain serotonin system to treat hallucinations and delusions associated with Parkinson's disease. Other antipsychotic medications, including Clozaril (clozapine) or Seroquel (quetiapine), are sometimes used instead. These drugs, which affect the dopamine and serotonin systems, are indicated for mood and thought disorders (such as schizophrenia) and before Nuplazid, these were among the only drug treatments available for PD psychosis.
Since Nuplazid does not affect the dopamine pathway, it typically does not worsen Parkinson's motor symptoms as do some of the other antipsychotics. It may improve nighttime sleep and daytime wakefulness, as well as lessen the stress that psychosis can place on a caregiver.
Cons and Complications
The most common side effects of Nuplazid are leg swelling, nausea and confusion; for Clozaril and Seroquel, they are drowsiness, weight gain (which may be mitigated by dietary changes) and associated diabetes, and worsening of Parkinson's motor symptoms. Clozaril also can decrease infection-fighting white blood cells and thus requires regular blood monitoring. These antipsychotics all carry a "black box" warning of increased risk of death in elderly people who have dementia. As with any medication, this and all other possible adverse effects need to be carefully assessed. Antipsychotic medications are considered only when symptoms are significant and the potential benefits of treatment outweigh the risks.
In men with Parkinson's disease, the most common sexual problem is erectile dysfunction. A variety of management options, including medication, are available. Drugs such as Viagra (sildenafil), Cialis (tadalafil) and Levitra (vardenafil) are typically used. The main potential side effect is low blood pressure.
Women with Parkinson's may experience pain with intercourse or vaginal dryness. Depending on her age and reproductive status, hormonal therapy (either hormone replacement therapy or oral contraceptives), medication for libido and/or lubrication may be prescribed. Read more on the Sexual Health webpage.
REM sleep behavior disorder (RBD) -- a condition in which people act out dreams because the normal suppression of muscle activity is impaired -- is common in Parkinson's. If RBD poses a safety risk or interferes with a person or their partner's sleep, treatment may be necessary. The most commonly recommended medications include either Klonopin (clonazepam) or melatonin (an over-the-counter hormonal supplement).
If Restless Legs Syndrome (RLS) -- an uncomfortable sensation in the legs and an urge to move them that improves only with movement or walking -- or nighttime motor symptoms interfere with sleep, adjustments of Parkinson's medications may be necessary.
For sleep problems or insomnia that persist despite behavioral and medication adjustments, prescription or over-the-counter sleep aids may be recommended. The former may include benzodiazepines -- such as Restoril (temazepam) -- or non-benzodiazepine sedatives, such as Ambien (zolpidem), Lunesta (eszopiclone) or Sonata (zaleplon). It's important to take any sleep medication only on the advice of your doctor since these could potentially worsen Parkinson's symptoms or interact with other medications.
People with Parkinson's often experience a need to urinate more urgently and more frequently, and this can lead to incontinence. Urinary symptoms can be treated with anticholinergic medications, which relax the bladder. Examples include Ditropan (oxybutynin) or Detrol (tolterodine). Unfortunately these drugs have a lot of potential side effects, including dry eyes and mouth, constipation, sleepiness and confusion, all of which can be more prominent in elderly people. Myrbetriq (mirabegron) works in a manner different than anticholinergics to relax the bladder and therefore has different side effects, the main one being high blood pressure. An alternative to oral medications is Botox (botulinum toxin) injections into the bladder muscles to temporarily relax them.
The medical information contained in this article is for general information purposes only. The Michael J. Fox Foundation has a policy of refraining from advocating, endorsing or promoting any drug therapy, course of treatment, or specific company or institution. It is crucial that care and treatment decisions related to Parkinson's disease and any other medical condition be made in consultation with a physician or other qualified medical professional.
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