DRUG TREATMENTS for Parkinson's

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DRUG TREATMENTS FOR Parkinson’s

1 There is no cure yet for Parkinson’s but there are The content in this booklet is designed to be dipped in and out many different drugs that can of – don’t feel like you need to help manage the symptoms. read everything in one go. This is particularly true because what This booklet is for people works for you when starting with Parkinson’s and their treatment for Parkinson’s may family, friends and carers. change later on. It provides information Reading the bits of this about the drugs most information that you need will commonly used to help also make this booklet more manage the condition. manageable and relevant for you.

This booklet starts with some key practical points about the drugs used for treating Parkinson’s, then gives further details about categories of drugs and individual drugs. There is also a summary that gives an overview list of Parkinson’s drugs.

Choosing the right medication is always a decision you should make with your specialist or Parkinson’s nurse. You can show this booklet to your specialist or Parkinson’s nurse and ask them questions about the information here. You may also find it a useful starting point when you are talking about the next steps in your treatment. Contents

Section 1 This gives an overview of Parkinson’s medication and is recommended for anyone with the condition.

Parkinson’s drugs: an introduction ...... 6 This includes how drugs work, their names and what treatment to take.

Other ways to manage your Parkinson’s ...... 9 This includes exercise and therapies.

Side effects of Parkinson’s drugs...... 10 This includes the main side effects you may experience.

Your Parkinson’s drugs: key points ...... 12 This includes tips for managing your Parkinson’s medication and taking it on time.

Other types of drugs you may take ...... 15 This includes drugs to avoid.

Section 2 This gives information on each type (class) of drug and then each specific branded and unbranded medication. You can read the parts that are relevant to you.

Levodopa ...... 17 This includes how it works, when it’s used as well as benefits, risks and side effects. Co-beneldopa (Madopar)...... 20 Co-careldopa (Sinemet, Caramet, Lecado and Apodespan)...... 22 Co-careldopa (Duodopa)...... 23

Dopamine agonists ...... 24 This includes how they work, when they’re used as well as benefits, risks and side effects. Pramipexole (Mirapexin, Pipexus, Glepark, Oprymea, Zentiva)...... 27 Ropinirole...... 28 Rotigotine (Neupro)...... 30 Apomorphine...... 30

MAO-B inhibitors ...... 32 This includes how they work, when they’re used as well as benefits, risks and side effects. Rasagiline (Azilect)...... 34 Selegiline (Eldepryl, Zelapar)...... 34 Safinamide (Xadago)...... 35

COMT inhibitors ...... 36 This includes how they work, when they’re used as well as benefits, risks and side effects. Entacapone (Comtess)...... 38 Co-careldopa and entacapone (Stalevo, Sastravi)...... 39 Opicapone (Ongentys)...... 39

Amantadine ...... 41 This includes how it works, when it’s used as well as benefits, risks and side effects.

Anticholinergics ...... 43 This includes how they work, when they’re used as well as benefits, risks and side effects. ProcyclidIne...... 45 Trihexyphenidyl (also called benzhexol)...... 45

4 Section 3 This gives a list of all Parkinson’s drugs and space to write down your specific treatment regime.

Parkinson’s drugs and how to pronounce them ...... 47 This includes a full list of Parkinson’s drugs. You can cut it out.

Notes...... 52 A blank page for you to write down notes you need. You can cut it out.

Medication record...... 53 This includes a table for you to write down your personal details and information about the specific drugs you take. You can cut it out and fill it in with your healthcare professionals.

More information and support...... 59

Disclaimer

We’ve made every effort to make sure the information in this booklet is correct at the time of printing. But Parkinson’s UK cannot take responsibility for the correctness, sufficiency or completeness of this information or any recommendation.

You should speak to a medical professional about your individual healthcare needs. Because everyone with Parkinson’s is different, Parkinson’s UK cannot advise on ideal combinations or provide details about the strengths or duration of action for each medication. Your specialist or Parkinson’s nurse will be able to give advice or information that’s relevant to your particular circumstances. You can also speak to a pharmacist for more information about how to take the medication you are prescribed.

Please remember that information about drugs can change. Also, this booklet does not list all the uses and side effects of different drugs. For full details, please see the drug information leaflet that comes with your medication. 5 Parkinson’s DRUGS: aN INTRODUCTION

How Parkinson’s drugs work Names of Parkinson’s drugs Dopamine is a chemical messenger Drugs for Parkinson’s can be made in the brain. The symptoms divided into three categories. of Parkinson’s appear when dopamine levels become too low. In this information, we have listed drugs in the following order to help This is because many of the cells in you see each category clearly. your brain that produce dopamine have died or are dying. Taking yyThe class or type of drug, dopamine as a drug doesn’t work for example levodopa. because it cannot cross the blood brain barrier. To get around this, yyThe generic (unbranded) name, doctors use other medication that such as co-beneldopa, which will can act in a similar way. include the active ingredients of the drug. For example, co- Most drug treatments work by doing beneldopa is a combination one or more of the following things: of levodopa and benserazide. yyThe brand name. For example, yyincreasing the amount Madopar is the name that the of dopamine in the brain pharmaceutical company, Roche, yyacting as a substitute for uses to sell co-beneldopa. dopamine by stimulating the parts of the brain where Your specialist will decide whether dopamine works to prescribe you branded or generic versions of your medication. It usually yyblocking the action of other depends on which area of the factors (enzymes) that break country you are in or what is most down dopamine common to prescribe in that area.

6 Once there are no longer any legal medical professionals to understand rights to the brand name any what medication you take. company can make generic (unbranded) versions of a drug. Modified release, controlled release and prolonged release The active ingredient of a generic medication drug is always the same as the You may see that your medication branded version and lots of people is written as modified release. It can won’t have any problems using also be written as controlled release the generic medication. (CR) or prolonged release (PR). All of these labels mean the same thing In the UK, a generic or branded but drug companies can choose medicine needs a licence and there which one to use with their drug. is a strict process for this. This means that the quality of a generic These types of medication are made or branded version of the same to release your treatment slowly to medicine will be the same, and help you have more even control of they will also act in the same way. your symptoms throughout the day.

If you find that you respond a bit What treatment will I take differently to generic medication, and when? discuss this with your specialist At diagnosis, you and your specialist or Parkinson’s nurse. will make a decision about whether to start treatment straight away The brand name will usually be the or wait until your symptoms cause most visible name on your packet you more problems. Usually you of medication. The generic name will be advised to start medication. is usually written in small print. You will be given specific times to take it which you should stick to. It is useful to keep the packaging for your medication. This will help you You will be prescribed levodopa, to remember what you are taking. a dopamine agonist or a MOA-B You can also record the name and inhibitor. Which medication you strength of your medication and take depends on how much your carry this list with you for when symptoms affect you and other you need it. This will be particularly factors such as your age and useful in an emergency as it will help your lifestyle.

7 Most people find they tolerate Parkinson’s nurse or pharmacist their treatment well and will return will work with you to find the best to clinic after six to eight weeks combination of treatment that to review their response. This is is best for you as an individual. when your specialist or Parkinson’s nurse will increase or decrease the Finding the best drug, dose and doses, the frequency, or add new timing won’t happen straight away. drugs until your symptoms are as Your treatment regime will usually controlled as possible. need adapting as your Parkinson’s symptoms change over time. Before leaving the clinic you should get the contact details of your Planning a medication routine is Parkinson’s nurse or the number something that should be a joint of the clinic in case you have any decision between you and your problems with side effects. See the healthcare professionals. If you are section on side effects further on prescribed medication, make sure in this information. you ask about what you are taking, when to take it, and any side effects. Medication is specific to you Your specialist or Parkinson’s nurse Every person with Parkinson’s has should explain things clearly and a different experience of the write down anything important. condition so your specialist,

8 OTHER WAYS TO MANAGE YOUR PARKINSON’S

Drug treatments are the main way Find out more about exercise and to manage Parkinson’s symptoms the styles to focus on at but other things can help. parkinsons.org.uk/exercise

Exercise Therapies Exercise is good for everyone and Therapies can complement your it is especially good for you if you treatment regime by focusing have Parkinson’s. It can be as on a specific issue you may have. important as your medication in managing symptoms. The three main types of therapy are physiotherapy, speech and Emerging evidence suggests that language therapy and occupational increasing exercise to 2.5 hours per therapy. week can slow the progression of your symptoms. Find out more: see our information on physiotherapy, speech and There is something for everyone language therapy and occupational so go for it. therapy.

9 SIDE EFFECTS OF Parkinson’s DRUGS

Like any drugs, Parkinson’s drugs can side effects should not put you off have side effects. This means that taking your medication to control some things you may think are your symptoms. Parkinson’s symptoms could be side effects of your medication. If you have a history of behaving impulsively you should mention Below we have listed some side this to your GP, specialist effects that are important to be or Parkinson’s nurse. aware of. We have also included specific side effects information Asking your specialist to make within each drugs class section. changes to your medication regime or adjusting the doses that you Impulsive and compulsive take is the easiest way to control behaviours impulsive and compulsive behaviours. So, if you or the person you care People who experience impulsive and for is experiencing this side effect, compulsive behaviours can’t resist tell your healthcare professional as the temptation to carry out an soon as possible before it creates activity – often one that gives large problems. immediate reward or pleasure. If you are not able to get through to Behaviours may involve gambling, your healthcare professional straight becoming a ‘shopaholic’, binge eating away, you can call our Parkinson’s UK or focusing on sexual feelings and helpline on 0808 800 0303. thoughts. This can have a huge impact on people’s lives including We have advice that can help you family and friends. manage impulsive and compulsive behaviours as well as information Not everyone who takes Parkinson’s on what behaviours to look out for. medication will experience impulsive and compulsive behaviours, so these 10 Find out more: see our Sleep issues information on impulsive Some Parkinson’s drugs can make and compulsive behaviours. you very sleepy. Sometimes this happens suddenly and without Hallucinations and delusions warning. Make sure you know what Hallucinations and delusions can also safety precautions you need to take have a huge impact on daily life. – if you can drive, for example.

A hallucination is when you see, Sometimes it can be hard to know hear or feel things that aren’t whether your sleep problems are there. Delusions are unusual part of the condition or whether they thoughts, beliefs or worries are a side effect of your Parkinson’s that aren’t based on reality. medication. It’s important to talk to your healthcare professionals to find They can happen with any Parkinson’s out the cause of these problems. medication but are more common with dopamine agonists. Not Find out more: see our information everyone will experience this side on driving and Parkinson’s and effect and it is more common in the sleep and night-time problems later stages of Parkinson’s. in Parkinson’s.

It’s natural to be worried about Blood pressure changes them but ask your doctor for clear Some Parkinson’s drugs can make information about hallucinations your blood pressure fall very and delusions before starting your quickly, causing you to feel dizzy medication if you have any concerns. or faint. Increasing the amount Talking about hallucinations and of liquid you drink can help. Your delusions with your healthcare specialist or Parkinson’s nurse will professional will mean they can be able to prescribe medication adjust your medication regime to ease this side effect and give to help reduce their impact. you other tips, so speak to them for more advice. Find out more: see our information on hallucinations and delusions. Find out more: see our information on low blood pressure and Parkinson’s.

11 YOUR Parkinson’s DRUGS: KEY POINTS

yyTry to take your medication forgot to take or take your late at the same set times every dose really close to your next one. day as advised by your specialist or Parkinson’s nurse. yyIf you are taking a once daily medication and you forget a dose, yyTell your specialist or Parkinson’s you can still take the dose if you nurse straight away if you remember on the same day. But, experience any side effects if you don’t remember until the from the drugs you take to treat following day you shouldn’t double Parkinson’s. Don’t stop taking up your dose. or change the dose or timing of your Parkinson’s drugs until Tips for managing your you have spoken to your health Parkinson’s medication professional as this can increase yy Ask your specialist, Parkinson’s your symptoms. nurse or pharmacist questions yyDo not stop taking your Parkinson’s if there’s anything you don’t medication unless your specialist understand or any symptoms or Parkinson’s nurse tells you to. you are particularly worried about. They won’t mind. You can yyIf you forget to take your dose, also ask for written information. take it as soon as you remember and then adjust the time of your yy Keep a diary or chart when next dose. For example, if you take your specialist team starts you doses at 8am, 12pm, 4pm and on a new drug, changes your 8pm and you forget your midday drugs or adjusts the dose or dose until 2pm, your next ones frequency. Record the dose and should be at 6pm and 10pm. time you took the drug and what happened to your symptoms. yyDo not take two doses together This can help you decide together to make up for a dose that you on how well the drug is working.

12 You can cut out, copy and use our Pill timers vary in cost, depending medication record at the end of on the type and who it is made this information. by. An occupational therapist or pharmacist can help you to choose yy You may want to wear the right option. The Disabled Living MedicAlert jewellery or carry our Foundation, an organisation that medication card to help people provides information on a range of know in an emergency situation equipment, can also advise you on that you have Parkinson’s and available options. You can call their what medication you take. helpline on 0300 999 0004. Remember to take your Help from your pharmacist medication on time Your pharmacist is well placed to We hear of many tools that people help you in your community when with Parkinson’s use to remind them you need them. It’s useful to go to take their medication on time. The to the same pharmacist each time trick is to find a solution to suit you. so they get to know you and your You can try using alarms on a digital condition. If you have trouble taking watch or setting a reminder on your medication, your pharmacist a smartphone. can arrange an assessment to see how they can help. For example, Pill timers they can offer large-print labels, A pill timer is a box that you can non-‘click top’ bottles or a store your Parkinson’s drugs in medication reminder chart. to remind you when to take each dose. They are useful if you have They may also be able to put your to take lots of different tablets or medication into a blister pack. This if you have trouble remembering means that each tablet has its own to take your medication. compartment linked to the correct time of day to remind you of your Some are divided into different times dose and when to take it. of day, so you can store all of your Parkinson’s drugs for one day. Others Managing Parkinson’s are big enough to hold your tablets medication while in hospital for a whole week, with sections for Make sure that hospital staff each day. Some weekly pill timers understand you have Parkinson’s are also split into times of day. and that you need your medication on time when you’re admitted to 13 their ward. Getting your medication Our Get It On Time resources can on time will mean your symptoms are help you to educate and remind staff well controlled and that you are likely about the importance of getting to experience fewer complications medication on time in hospital. from being in hospital. Find out more: see our range Some hospitals will allow you to look of Get It On Time resources. after your own medication, so that you can take it yourself outside of the usual drugs round.

14 OTHER TYPES OF DRUGS YOU MAY TAKE

People with Parkinson’s can have These are some (but not all) symptoms that aren’t connected of the drugs to avoid in Parkinson’s: to movement problems, known as non-motor symptoms. These include yy chlorpromazine (Largactil) anxiety, pain and constipation. yy fluphenazine (Modecate) These types of symptoms may be yy perphenazine (Fentazin/ treated with the same drugs used Triptafen) by everyone with that health issue, rather than Parkinson’s-specific yy trifluoperazine (Stelazine) drugs. For example, you may be yy flupentixol (Fluanxol/Depixol) prescribed Movicol for constipation. Parkinson’s and the drugs used to yy haloperidol (Serenace/Haldol) treat it can interact with the drugs used for other conditions. This means yy metoclopramide (Maxalon) that a particular drug can become yy prochlorperazine (Stemetil) weaker or stronger. Your specialist or pharmacist can advise you on this. Complementary therapies Always ask them before buying any Herbal or complementary treatments over the counter medication. may also affect your Parkinson’s drugs. For example, St John’s Wort Drugs to avoid is not recommended for people with Some drugs can bring on Parkinson’s- Parkinson’s. It is made up of many like symptoms or react badly with elements which can interact with Parkinson’s drugs and should be your Parkinson’s medication and avoided unless they’re recommended cause side effects. So always check by a specialist. with your specialist, Parkinson’s nurse or pharmacist before taking alternative medicines.

15 Cold remedies If you are prescribed this Many decongestants and cold medication, your specialist, remedies can stop your Parkinson’s Parkinson’s nurse or pharmacist medication working properly. should talk to you about how This is especially important to to recognise signs of irregular remember if you are taking selegiline, heart rhythms. A test of your rasagiline and safinamide. They can pulse or another examination is also increase the risk of side effects. often routinely performed to check Always check with your pharmacist for irregular heart rhythms before before taking cold remedies. you are prescribed domperidone or ondansetron (see below). Anti-sickness drugs Parkinson’s medication can cause Other anti-sickness drugs that nausea and vomiting. Doctors will are generally considered useful usually prescribe domperidone include cyclizine (Valoid) and (Motilium) to prevent and treat 5-HT3 receptor antagonists this side effect. like ondansetron.

Domperidone can cause heart rhythm problems (arrhythmia).

LEVODOPA

Levodopa is the name used to yy Sinemet (tablets) describe one of the main classes of Parkinson’s drugs. yy Sinemet Plus (tablets) yy Sinemet CR (controlled Below are the types of levodopa release tablets) drugs. The generic names are written in bold and the brand names are yy Duodopa (intestinal gel) written underneath in bullet points. Co-careldopa and entacapone See the section on the names of (See COMT inhibitors section) Parkinson’s drugs to find out more. yy Stalevo (tablets) Types of levodopa yy Sastravi (tablets) yy Stanek (tablets) Co-beneldopa yy Madopar (capsules, Entacapone dispersible tablets) yy Comtess (tablets) yy Madopar CR (controlled release capsules) How do Levodopa drugs work? Co-careldopa Levodopa is a chemical building yy Apodespan PR (prolonged block that your body converts into release tablets) dopamine in the brain. Levodopa already occurs naturally in your yy Caramet CR (controlled body and taking a levodopa drug released tablets) treatment boosts the supply, yy Lecado (modified release tablets) meaning the nerve cells can make more dopamine. yy Half Sinemet CR (controlled release tablets)

17 When are levodopa The patient information leaflet that drugs used? comes with your drugs will tell you the full range of side effects that Levodopa drugs are sometimes you may experience but some one of the first types of medication possible ones include: that people with Parkinson’s are prescribed. However, this will not Wearing off be the same for everyone. When you take levodopa for a long

time you may experience wearing Your levodopa treatment will usually off. This is when your drugs wear start with a low dose. This will off before you take the next dose gradually be increased until your so you have times when you’re stiff symptoms are under control. and slow.

Benefits of levodopa Involuntary movements Levodopa can help treat Parkinson’s (dyskinesia) symptoms because it helps to top With long-term use of levodopa up dopamine levels in the brain. you may experience involuntary movements (dyskinesia). These You may experience a big are muscle movements that improvement in your symptoms you can’t control. They can when taking it, especially with include twitches, jerks, twisting stiffness and slowness of movement. or writhing movements.

Risks and side effects Impulsive and compulsive of levodopa behaviours Levodopa becomes less effective Impulsive and compulsive behaviours over time. This is because it cannot can happen with any Parkinson’s stop the dopamine producing cells drugs. See the section on side from being lost so you will continue effects of Parkinson’s drugs to to get symptoms. This means that find out more. more frequent doses are needed. Withdrawal syndrome Your brain can’t become resistant to with levodopa levodopa. People with Parkinson’s will Research has shown that benefit from medications containing withdrawal symptoms can levodopa throughout their lifetime. happen when someone stops taking levodopa medication 18 very suddenly, perhaps because yy hallucinations (seeing, hearing, they are experiencing impulsive feeling and smelling things that and compulsive behaviour. aren’t there)

It can lead to symptoms including Levodopa and protein depression, anxiety or pain, and in For some people with Parkinson’s, the most serious cases, effects protein (which is found mainly can lead to hospitalisation. in meat, fish, eggs, cheese, beans and pulses) seems to interfere with Any withdrawal from Parkinson’s how well levodopa medications are drugs needs to be done gradually, absorbed by the body. Because under the supervision of a health of this, you may benefit from taking professional, to avoid the risk your medication 30 to 60 minutes of developing this syndrome. before you eat a meal. Iron However, levodopa drugs can When you take your levodopa sometimes make people feel sick. medication it may help to avoid any Eating a low protein snack (such as medicines or vitamin supplements crackers) when you take your dose with iron in them. Iron can mean that may help to reduce this side effect. less levodopa gets into the parts of You may also benefit from a protein the body where it is needed. Talk to redistribution diet, where you take your healthcare professional for more most of your daily protein in the information about this. evening. This can help the levodopa treatment to be more effective Other side effects in the daytime, when you are likely Other common side effects include: to need it more. yy nausea and vomiting Protein is essential for a healthy diet so you should not reduce your yy low blood pressure (hypotension) overall intake. Talk to your specialist yy loss of appetite or Parkinson’s nurse before you make any changes to what you eat. yy anxiety and depression see our information yy sleep problems Find out more: on diet.

19 Co-beneldopa (Madopar) Taking co-beneldopa Co-beneldopa is a type of generic (Madopar) (unbranded) levodopa medication. Below we have included the Madopar is the brand name for different forms of co-beneldopa co-beneldopa. (Madopar) medication and some key points on taking them. It contains two ingredients, levodopa and benserazide. The most recent and complete The benserazide ingredient helps information on your specific drug will levodopa get into the brain where be on your patient information leaflet it can be converted to dopamine. that comes with your medication packet. Always read it carefully The dose of co-beneldopa before you start your treatment. (Madopar) is expressed with the levodopa content first and For detailed information you then the benserazide content. should follow the advice of your For example, Madopar 50/12.5 specialist or Parkinson’s nurse contains 50 mg levodopa and about how to take co-beneldopa 12.5 mg of benserazide. (Madopar) so that it works well for your Parkinson’s. 20 Immediate-release co-beneldopa Co-beneldopa dispersible tablets capsules (Madopar capsules) (Madopar tablets) Taking this medication with a meal, These dispersible tablets can or shortly after it, will mean you are be mixed with water to make less likely to experience any nausea. a drink. It takes effect more quickly If you don’t experience nausea than capsules because it doesn’t it may be beneficial to take your need to be broken down in your capsules 30 – 40 minutes before stomach to release the active a meal to help your medication work. ingredient. It can also be used if you have trouble swallowing Controlled release co-beneldopa tablets or capsules. capsules (Madopar CR capsules) Controlled release co-beneldopa You should take these tablets capsules (Madopar CR) let the with water or fruit squash. levodopa enter your body slowly instead of all at once. They are Taking this medication with a meal particularly helpful if they are taken or after it will mean you are less before going to bed to reduce likely to experience any nausea. stiffness during the night. Co-beneldopa dispersible tablets Controlled release co-beneldopa (Madopar tablets) are useful capsules (Madopar CR capsules) can if you experience slowness of also help to reduce one of the side movement or the ‘on/off’ effect. effects of levodopa medication - See the section on side effects of involuntary movements (dyskinesia). Parkinson’s drugs to find out more.

You should take the capsules with a good drink of water. Don’t break, crush or chew them.

Drugs for indigestion, heartburn, or an upset stomach can make it more difficult for your body to absorb your controlled-release capsules. So avoid this type of medication in the two hours before and after you take co-beneldopa (Madopar) capsules.

21 Co-careldopa (Sinemet, Always read it carefully before you Caramet, Lecado and start your treatment. Apodespan) For detailed advice you should Co-careldopa is a type of generic speak to your GP, specialist (unbranded) levodopa medication. or Parkinson’s nurse about Sinemet, Caramet, Lecado and how to take co-careldopa so that Apodespan are the branded it works well for your Parkinson’s. versions of co-careldopa. Co-careldopa (Sinemet, Co-careldopa contains two Sinemet Plus tablets) ingredients, levodopa and carbidopa. You will usually take Sinemet The carbidopa ingredient helps or Sinemet Plus three or four levodopa get in to the brain where times a day. But this will vary and it can become dopamine. Carbidopa your healthcare professional will be also helps to make sure you best placed to advise you on what experience fewer side effects. dose is best for your Parkinson’s.

The dose of co-carledopa (Sinemet) is expressed with the Co-careldopa (Sinemet controlled carbidopa content first and then release tablets) the levodopa content. For example, Co-careldopa controlled release Sinemet 12.5/50 contains carbidopa lets the levodopa enter your body 12.5 mg and levodopa 50 mg. slowly instead of all at once. This is particularly helpful if taken before going to bed to reduce stiffness Taking co-careldopa during the night. (Sinemet, Caramet, Lecado, Apodespan) Co-careldopa controlled release Below we have included the tablets mean that your medication different forms of co-careldopa takes effect slowly during the day. medication and some key points Your dose can be adjusted by your on taking them. specialist or Parkinson’s nurse so that your symptoms are well controlled. The most recent and complete information on your specific drug You should take these tablets whole. will be on your patient information Don’t break, crush or chew them leaflet that comes with your because they have been made to medication packet. release your medication slowly. 22 Benefits and risks of Duodopa gel can help reduce: taking co-beneldopa y and co-careldopa y involuntary movements as a side effect of your medication Co-beneldopa (Madopar) and Co-careldopa (Sinemet, Caramet, yy motor fluctuations from your Lecado and Apodespan) are common drugs wearing off drugs used to treat Parkinson’s and y most people will experience an y problems with your symptoms improvement in their symptoms. at night

See our levodopa section for an When is Duodopa used? overview of the side effects you It is only suitable for a small number may experience. of people whose symptoms can’t be controlled with more common drug Co-careldopa (Duodopa) treatments, such as levodopa tablets. Duodopa is a gel form of levodopa It is most often used when (co-careldopa) medication used for Parkinson’s symptoms have advanced and complex Parkinson’s. progressed.

It is pumped through a tube that Find out more at is surgically inserted into the parkinsons.org.uk/levodopa intestine. This means your dose of medication acts more quickly.

DOPAMINE AGONISTS

Dopamine agonists is the name Ropinirole used to describe a class of yy Adartrel (tablets) Parkinson’s drugs. yy Ralnea XL (prolonged Below are the types of dopamine release tablets) agonist drugs. The generic names are yy Requip (tablets) written in bold and the brand names are written underneath in bullet yy Requip XL (prolonged points. See the section on names of release tablets) Parkinson’s drugs to find out more. yy Spiroco XL (prolonged release tablets) Types of dopamine agonists yy Ipinnia XL (prolonged release tablets) Pramipexole yy Raponer XL (prolonged yy Mirapexin (tablets) release tablets) yy Mirapexin (prolonged yy Ropilynz XL (prolonged release tablets) release tablets) yy Pipexus (modified Rotigotine release tablets) yy Neupro (skin patch) yy Glepark (tablets) Apomorphine yy Oprymea (tablets) yy Apo-go pre-filled pen for intermittent injection yy Zentiva (prolonged release tablets) yy Dacepton cartridge for intermittent injection (can be used with a re-usable pen) 24 yy Apo-go pre-filled syringe for Lowers levodopa medication infusion (can be used with Taking dopamine agonists may mean a continuous infusion pump) you can take lower doses of levodopa as your condition progresses. This yy Dacepton vial (can be used with can reduce the risk of involuntary DOPAMINE AGONISTS a continuous infusion pump) movements (dyskinesia) and how much they affect you. How do dopamine agonists work? Helping levodopa work better Dopamine agonist drugs trick Dopamine agonists can be taken with your brain into thinking they are levodopa medication to help when dopamine. This means they can levodopa wears off or doesn’t work mimic the way dopamine works as well. This is because dopamine which can reduce your symptoms. agonists work for longer in the body and can reduce the ‘on/off’ effect When are dopamine you may have with levodopa. agonists used? Dopamine agonists are typically Fewer tablets to take prescribed in the earlier stages of There are some once-daily Parkinson’s but everyone is different preparations that could reduce the and you could be prescribed them number of tablets you take in some at any time if it is right for you. cases. But this option may not be suitable for everyone. Treatment with dopamine agonists has to be started carefully. The dose Treating restless legs is gradually increased until you and Dopamine agonist medications your specialist team are happy that can be used for people who have your symptoms are under control. restless legs syndrome, also called Willis-Ekbom disease. Your Benefits of dopamine healthcare professional will decide which specific drug to prescribe. agonists

Delaying levodopa treatment Restless legs syndrome can be Dopamine agonists may be an connected to Parkinson’s or it can effective treatment for several years be a separate condition. You may when used alone or with levodopa. experience tingling in your legs and But this won’t be true for everyone. you may have an urge to move them. 25 Check with your healthcare Some people have experienced professional for specific advice on a sudden onset of sleep, without when to take dopamine agonist any warning. If this happens, medication you are prescribed for it’s important that you tell your restless legs syndrome. specialist or Parkinson’s nurse.

Find out more: see our Impulsive and compulsive information on restless legs. behaviours and hallucinations and delusions These side effects can happen with Risks and side effects any Parkinson’s drugs but are more of dopamine agonists common with dopamine agonists. See the section on side effects Heart problems of Parkinson’s drugs to find out more. Some of the older dopamine agonists increase the risk of heart and lung Other side effects problems. They are known as ‘ergot’ types and include bromocriptine, The patient information leaflet that pergolide and cabergoline. Because comes with your medication will tell of this risk, these Parkinson’s drugs you the full range of side effects are no longer recommended and we that you may experience. haven’t included them here. Some possible side effects include:

Newer dopamine agonists are yy nausea known as non-ergot. These are pramipexole, ropinirole, rotigotine yy constipation and apomorphine. They have not been associated with a risk of heart yy low blood pressure (hypotension) damage and can be prescribed. yy headaches Sleepiness and fainting yy anxiety and depression Dopamine agonist drugs can make yy movement problems you sleepy, faint or dizzy. This is most likely to happen when you start taking them. Once you reach a stable dose, this effect often wears off.

26 Taking pramipexole to experience wearing off and (Mirapexin, Pipexus, dyskinesia. This could be motor Glepark, Oprymea, Zentiva) fluctuations, or wearing off before your next dose of levodopa is due. Below we have included the different forms of pramipexole Pramipexole tablets (Mirapexin, (Mirapexin, Pipexus, Glepark, Pipexus, Glepark, Oprymea Oprymea, Zentiva) medication and or Zentiva) an overview of how to take them. Swallow the tablets with a drink of water. You can take your doses The most recent and complete before or after meals. information on your specific drug will be on your patient information leaflet Your specialist or Parkinson’s nurse that comes with your medication will be able to advise you on the packet. Always read it carefully best dose. Usually you will be given before you start your treatment. these tablets on a low dose at first which will be increased roughly For detailed information you should every five to seven days until it is follow the advice of your specialist right for you and your symptoms. or Parkinson’s nurse about how to take pramipexole so that it works You will usually take Mirapexin three well for your Parkinson’s. times a day but your specialist or Parkinson’s nurse will be best placed Pramipexole drugs are also used to advise you on this. to help your symptoms when your levodopa medication causes you

27 Pipexus and Mirapexin yy Requip XL (prolonged (prolonged release tablets) release tablets) You should take the capsules with yy Spiroco XL (prolonged a drink of water. Don’t break, crush release tablets) or chew them. This is because they have been made to release the yy Ipinnia XL (prolonged medicine slowly over the course release tablets) of the day. You can take them yy Raponer XL (prolonged with or without food. release tablets)

Your healthcare professional will yy Ropilynz XL (prolonged be able to advise you on the best release tablets) dose. But usually you will be given these tablets on a low dose at first Ropinirole medication can be which will be increased roughly used as a substitute for dopamine every five to seven days until it is because it can have an effect right for you and your symptoms. on the same nerve cells where dopamine works. Ropinirole can You will be prescribed Pipexus or be used alone or with other Mirapexin (controlled release tablets) medications to treat Parkinson’s. once a day. This can make it easier for you to remember your dose. Taking ropinirole (Requip, Adartel, Requip XL, Ralnea Ropinirole XL, Spiroco XL, Ipinnia XL, Ropinirole is a type of generic Raponer XL or Ropilynz XL) (unbranded) dopamine agonist medication. Below we have included the different forms of ropinirole There are a number of brand names medication and an overview for ropinirole. These are: of how to take them.

yy Adartrel (tablets) The most recent and complete information on your specific drug will yy Ralnea XL (prolonged be on your patient information leaflet release tablets) that comes with your medication packet. Always read it carefully yy Requip (tablets) before you start your treatment. For detailed information you should 28 follow the advice of your doctor yy You should take these tablets about how to take ropinirole so that once a day. it works well for your Parkinson’s. yy These tablets can be taken with Ropinirole (Requip, Adartel) or without food. Ropinirole (Requip, Adartel) is taken yy It is important that you take as one dose per day, usually just these tablets whole. They must before bedtime or around three not be chewed, crushed or hours beforehand. Your healthcare divided into pieces. professional can then increase your dose during the rest of the first week At first your specialist will prescribe if you don’t experience side effects. you a low dose of Ralnea XL, Requip XL, Spiroco XL, Ipinnia XL, Raponer However your specialist or XL or Ropilynz XL. This will usually Parkinson’s nurse will be best be once per day for an initial period placed to advise you on when to of one week. Your healthcare take ropinirole so that it works well professional can then increase for your condition. They can increase your daily dose until it is right your daily dose over time until it is for you and your symptoms. right for you and your symptoms. Taking ropinirole with your meals In some cases, a high fat meal may will help to reduce any stomach create issues so speak to your issues that you may experience. specialist if you think that food is creating problems when you take Ropinirole prolonged release your medication. tablets (Ralnea XL, Requip XL, Spiroco XL, Ipinnia XL, Raponer XL, Ropilynz XL) Tell your doctor if you experience side effects from any of these Prolonged release tablets release prolonged release tablets as other your medication slowly throughout forms of ropinirole medication may the day. This can give you more be more suitable for you. control of your symptoms. They can be taken alone to try and delay the need for you to take levodopa. This can be helpful because levodopa becomes less effective over time.

29 Benefits and risks of How can a skin patch help? pramipexole and ropinirole It may be useful if: medication y Pramipexole and ropinirole y you have trouble swallowing medication is commonly used to tablets treat Parkinson’s and most people yy you experience wearing off will experience an improvement of your levodopa medication in their symptoms. yy you experience fluctuations See the section on risks and side in the way your levodopa effects of dopamine agonists for medication works an overview of the side effects yy you experience restless legs you may experience. syndrome (an uncontrollable urge to move your legs) For the full range of side effects, see the patient information leaflet Find out more at that comes with your medication. parkinsons.org.uk/rotigotine

Rotigotine (Neupro) Apomorphine The brand name of rotigotine Apomorphine is a strong dopamine is Neupro. It is a skin patch which agonist that stimulates the same is applied to different areas of the areas of the brain as dopamine. skin and releases the drug slowly. Apomorphine is injected or infused How does the skin through a pump. It also comes in patch work? a pen, cartridge or vial. The brand Neupro is placed on your skin once names for apomorphine are Apo-go at the same time every day. You and Dacepton. should hold the patch in place for 30 seconds to allow the drug to start Apomorphine is often used working. It can stay in place for 24 to improve symptoms quickly. hours before you apply a new one. It may be helpful if:

If you forget to apply the patch at yy your symptoms are unpredictable your usual time or if it falls off, put because of the ‘on-off’ effect on a new one for the rest of the day. of your medication

30 yy oral drug treatments have If you need more than 10 injections become less effective or a day, you may be changed stopped working to a continuous infusion.

How does apomorphine Continuous infusion is when work? medication is delivered non-stop into your body via a small battery- Apomorphine injections are taken driven pump. This uses a fine tubing with a ready-to-use pen that you with a small needle at the end, inject seven to 10 times a day. which is inserted under the skin. It works within five to 10 minutes. Find out more: see our Dacepton is a brand of permanent pen with cartridges to refill. information on apomorphine.

31 MAO-b inhibitors

MAO-B inhibitors How do MAO–B MAO-B inhibitors is the name inhibitors work? used to describe a class of MAO–B inhibitors can help your Parkinson’s drugs. nerve cells make better use of the dopamine that they have. Below are the types of MAO-B inhibitor drugs. The generic names Monoamine oxidase type B is an are written in bold and the brand enzyme that wrongly hoovers up names are written underneath dopamine that is not being used in bullet points. See the section by your brain. MAO-B inhibitors on names of Parkinson’s drugs stop this enzyme so that more to find out more. dopamine becomes available to treat your symptoms. Types of MAO-B inhibitors MAO-B inhibitors take two to three Rasagiline weeks to work and when you stop yy Azilect (tablets) this medication it will be two to three weeks before they stop working. Selegiline yy Eldepryl (tablets) When are MAO–B inhibitors used? yy Zelapar (tablets that dissolve on the tongue) A MAO–B inhibitor can be used on its own in early Parkinson’s Safinamide when your motor symptoms are yy Xadago (tablets) controlled and mild. It can also be used with other drugs at any stage. Later on it can help with motor fluctuations.

32 Benefits of MAO–B inhibitors Your specialist should be able to advise you on how to take You don’t need to start gradually antidepressants alongside your Many drug treatments for Parkinson’s medication. Parkinson’s have to be started Decongestants or cold remedies gradually, with the dose slowly being These can affect some types of increased over time. This is not the MAO–B inhibitors. If you need case for most MAO-B inhibitors. to use them, check with your pharmacist to find out which Delaying levodopa treatment one is safe for you to use. By taking a MAO–B inhibitor at an early stage of Parkinson’s, you may Worse levodopa side effects be able to delay taking levodopa until your symptoms become more Involuntary movements difficult to manage. (dyskinesia) and sickness may get worse because MAO–B inhibitors Helping levodopa work well strengthen the effects of levodopa. If this happens, your specialist or When you have been taking levodopa Parkinson’s nurse can reduce your for a while, you may find that its dose of levodopa. effects wear off too quickly. A MAO–B inhibitor can help. Impulsive and compulsive behaviours Taking a MAO–B inhibitor may also Impulsive and compulsive behaviours mean you can take less levodopa can happen with any Parkinson’s and leave more time between doses. drugs. See the section on side effects of Parkinson’s drugs to find out more. Risks and side effects of MAO–B inhibitors Increased risk of low blood pressure Antidepressants If you take a high dose of MAO-B If you’re taking some types of inhibitor medication, eating and antidepressant, you might not drinking certain things can increase be able to take MAO–B inhibitors. low blood pressure. Because of the This is because these drugs can doses used in Parkinson’s this is not interact with each other and raise thought to be a problem, but speak blood pressure to a dangerous level. to your specialist or Parkinson’s nurse if you have any concerns. 33 Other side effects You will take rasagiline once per The patient information leaflet that day, which can be helpful if you comes with your medication will tell prefer to take fewer doses. But be you the full range of side effects aware that this option may not be that you may experience. suitable for everyone. You can take it with or without food. Some of the possible side effects include: Selegiline (Eldepryl, Zelapar) Selegiline is a type of generic yy headaches (unbranded) MAO-B inhibitor medication. Eldepryl and Zelapar yy constipation are the branded versions of selegiline. yy dry mouth Selegiline is started at 5 mg and yy an urgent need to pass urine increased after two to four weeks yy aching joints to 10 mg. yy indigestion Eldepryl tablets You will usually take Eldepryl yy flu-like symptoms tablets once per day. However yy depression there is also the option of taking one in the morning and then one Rasagiline (Azilect) at lunchtime. Your specialist team Rasagiline is a type of generic can advise you on the best time (unbranded) MAO-B inhibitor to take Eldepryl for your Parkinson’s. medication. Azilect is the brand name. Eldepryl tablets can delay the need to take levodopa which is helpful as levodopa can become less effective Taking rasagiline (Azilect) over time. Rasagiline can be taken alone. It can also be taken with levodopa to help Eldepryl can also be taken with stop motor fluctuations that happen levodopa to help stop motor at the end of your dose or before fluctuations that happen at the your next one is due. end of your dose before your next one is due.

34 Zelapar dissolvable tablets Benefits and risks of Selegeline is available as tablets rasagiline, selegiline which dissolve on the tongue and safinamide (Zelapar dissolvable tablets). This Rasagiline (Azilect), selegiline can be helpful if you experience (Eldepryl, Zelapar) and safinamide problems with swallowing. (Xadago) are commonly used to treat Parkinson’s and most people To take Zelapar tablets, put one on will experience improvement your tongue before eating breakfast. in their symptoms. You should wait five minutes for it to dissolve before eating, See the section on the risks and drinking, or rinsing your mouth side effects of MAO-B inhibitors so this medication can work. to find out more.

Safinamide (Xadago) For the full range of side effects, Safinamide is a type of generic see the patient information leaflet (unbranded) MAO-B inhibitor that comes with your medication. medication. Xadago is the branded version of safinamide.

Safinamide medication is taken as an addition to your regular dose of levodopa medication. It can also be taken with other medication if your condition has progressed to help reduce motor fluctuations.

Taking safinamide (Xadago) You will take safinamide (Xadago) once per day with water and with or without food. This can be helpful if you prefer to take fewer doses. But be aware this option may not be suitable for everyone. Your healthcare professional will be best placed to advise you when to take safinamide (Xadago) medication.

35 COMT inhibitors

COMT inhibitors is the name used to How do COMT describe a class of Parkinson’s drugs. inhibitors work? Levodopa can boost the supply Below are the types of COMT of dopamine in your brain. COMT inhibitor drugs. The generic names inhibitors can block an enzyme that are written in bold and the brand breaks down levodopa medication. names are written underneath in This helps it to work more effectively. bullet points. See the section on names of Parkinson’s drugs to find out more. When are COMT inhibitors used? Types of COMT inhibitors COMT inhibitors do not help to manage the symptoms of Parkinson’s on their own – they Entacapone have to be used with levodopa. yy Comtess (tablets) Your specialist might prescribe Co-careldopa and entacapone them if your dose of levodopa yy Stalevo (tablets) is not working for long enough. yy Sastravi (tablets) It will also help your levodopa yy Stanek (tablets) medication to work more smoothly in controlling your symptoms. Tolcapone y y Tasmar (tablets) Benefits of COMT inhibitors Opicapone yy Ongentys (tablets) Helping levodopa work smoothly COMT inhibitors can help when levodopa is not working for long enough and starts to wear off 36 between doses.They can help Worse levodopa side effects to reduce your ‘off’ time, when Involuntary movements you have more trouble with your (dyskinesia) and sickness may get Parkinson’s symptoms, and increase worse because COMT inhibitors the amount of ‘on’ time, when your strengthen the effects of levodopa. symptoms are more controlled. If this happens, your specialist or Parkinson’s nurse can reduce your Taking less levodopa dose of levodopa. In many cases, you will be able to take a lower dose of levodopa and Impulsive and compulsive less often. behaviours Impulsive and compulsive Risks and side effects behaviours can happen with of COMT inhibitors any Parkinson’s medication. See the section on side effects of Parkinson’s drugs to find out more. Coloured urine and diarrhoea COMT inhibitors will colour your Other side effects urine a bright reddish orange colour The patient information leaflet that but this isn’t harmful. comes with your medication will tell You may experience diarrhoea you the full range of side effects weeks or months after starting that you may experience. co-careldopa and entacapone Some of these side effects include: (Stalevo, Sastravi, Stanek). If this happens contact your specialist y sleeping problems or Parkinson’s nurse for advice. y yy loss of appetite Liver damage y With tolcapone (Tasmar), there is a y dizziness risk of liver damage that can be fatal yy fainting and you will need regular blood tests to check the health of your liver. yy falls It is rare, but for this reason, it is only yy hallucinations used if you can’t take entacapone, where no risk of liver damage has yy headaches been seen. Because of this we have not included further information yy confusion about tolcapone here. 37 yy dry mouth Below we have included an overview of how to take yy chest pain entacapone (Comtess) medication. yy sleepiness yy You should take entacapone If you are allergic to peanuts or soya, (Comtess) tablets at the same make sure you tell your specialist and time as your co-beneldopa, Parkinson’s nurse as you may not be or co-careldopa levodopa able to take some COMT inhibitors. medication. yy Entacapone increases the Entacapone (Comtess) effectiveness of your co- Entacapone is a COMT inhibitor beneldopa, or co-careldopa drug used to manage the symptoms levodopa medication. But too of Parkinson’s. The brand name of much levodopa can create entacapone is Comtess. side effects. So when you start taking entacapone, your If you’ve had Parkinson’s for some specialist or Parkinson’s nurse time and your symptoms get worse may need to adjust the amount between each dose of medication, of levodopa that you take. you may be prescribed entacapone (Comtess). It works to increase yy You can take your entacapone the effectiveness of the levodopa medication before you eat medication you are taking and stop it a meal. from being broken down in the body. yy When you take your entacapone (Comtess) tablets it may help Taking entacapone (Comtess) to avoid any medicines or The most recent information on vitamin supplements with iron your specific medication will be in them. Iron can mean that less on your patient information leaflet entacapone gets into the parts that comes with your packet. of the body where it is needed. Always read it carefully before Talk to your specialist or you start your treatment. Parkinson’s nurse for more information about this. For detailed advice you should speak to your healthcare professional about how to take entacapone so that it works well for your Parkinson’s.

38 Co-careldopa and Opicapone (Ongentys) entacapone (Stalevo, Opicapone (Ongentys) is a type of Sastravi) COMT inhibitor medication. If you Stalevo and Sastravi are branded take levodopa for a long time, you versions of co-careldopa and may experience end of dose motor entacapone medication. This fluctuations when your symptoms means they combine the levodopa are poorly controlled before your medication co-careldopa (see next dose is due. If this happens the section on co-careldopa) you can take opicapone with with entacopone (see the your levodopa medication to section on entacapone). ease this issue.

The entacapone helps to make the Opicapone strengthens your levodopa component stronger which levodopa medication to make it work can help you control your symptoms. better than when it is taken alone.

Using this combination drug also Taking opicapone (Ongentys) means that it is convenient for The most recent and complete people to take. information on your specific drug will be on your patient information leaflet Taking co-careldopa and that comes with your medication entacapone (Stalevo, Sastravi) packet. Always read it carefully You may be prescribed co-careldopa before you start your treatment. and entacapone (Stalevo and Sastravi) if levodopa medication For detailed information you should alone is not able to control motor follow the advice of your healthcare fluctuations you experience at the professional about how to take end of your dose. opicapone (Ongentys) so that it works well for your Parkinson’s. The maximum dose of Stalevo and Sastravi medication is usually seven You should take opicapone once to 10 tablets, depending on the a day at bedtime. You should do strength you are prescribed. this at least one hour before or after your levodopa medication. Your healthcare professional will be best placed to advise you on when Because opicapone is taken with to take your medication and exactly levodopa to make it work well and how much to take. reduce side effects, your healthcare 39 professional may need to adjust treat Parkinson’s and most people the amount of levodopa you take. will experience an improvement You should discuss this with them. in their symptoms.

Benefits and risks of See the section on the risks and entacapone, co-careldopa side effects of COMT inhibitors and entacapone, and to find out more. opicapone For the full range of side effects, Entacapone (Comtess), co-careldopa see the patient information leaflet and entacapone, and opicapone that comes with your Ongentys (Ongentys) is commonly used to medication.

40 Amantadine

Amantadine Amantadine is usually given with Amantadine is the only glutamate other drug treatments. It is started antagonist drug that is prescribed at a lower dose and the amount to treat Parkinson’s. It is an is stepped up gradually. unbranded form of Parkinson’s medication, which comes in the Benefits of amantadine form of capsules and syrup. National guidelines say there is not enough scientific evidence to When is amantadine used? support this drug as a first choice in early Parkinson’s. Amantadine isn’t used as much as other Parkinson’s medication But for some people, later on, and is not usually prescribed alone. amantadine may reduce involuntary movements (dyskinesia) caused There isn’t much evidence that by your other Parkinson’s drugs, amantadine can improve tremor without making your Parkinson’s and other motor symptoms of symptoms worse. Parkinson’s. But it can be used to treat involuntary movements Amantadine can also help to reduce (dyskinesia) if other Parkinson’s stiffness you may experience in medication has not been effective. your muscles.

Amantadine is often prescribed Risks and side effects when other medication is no longer working as well but it can be used of amantadine at all stages of Parkinson’s. Limited effect on Parkinson’s Amantadine is not a first choice for the treatment of Parkinson’s and it may have only a mild effect. 41 Over time, people can become used (postural hypotension). to this medication and amantadine Also, If you have these side can become less effective. effects, it is not safe to drive or use machinery. Impulsive and compulsive behaviours yy headaches, poor concentration Impulsive and compulsive behaviours yy hallucinations, delusions can happen with any Parkinson’s and paranoia drugs. See the section on side effects of Parkinson’s drugs to find out more. yy movement problems yy sleep problems Other side effects People who use amantadine as yy fast or irregular heartbeat (this a treatment for their Parkinson’s find can be linked to swelling that it improves their symptoms, in the feet or ankles, known particularly when other Parkinson’s as oedema) drugs are creating issues. yy loss of appetite and weight loss

For the full range of side effects, yy dry mouth see the patient information leaflet yy nausea and vomiting that comes with your amantadine medication. yy sweating

See the section on side effects of yy problems with speech Parkinson’s drugs to find out more. yy skin reactions Some of the other possible side effects you may experience with amantadine include:

yy feeling nervous or anxious yy blurred vision, fainting, confusion or dizziness. These symptoms may be linked to low blood pressure when changing position

42 Anticholinergics

Anticholinergics Anticholinergics is the name used to In Parkinson’s the effect describe a class of Parkinson’s drugs. of acetylcholine is stronger. This can lead to part of the brain Below are the types of anticholinergic becoming overactive and you may drugs. The generic names are experience a tremor. Reducing written in bold and the brand names the effect of acetylcholine can are written underneath in bullet help to treat tremor. points. See the section on names of Parkinson’s drugs to find out more. When are anticholinergics used? Types of anticholinergics Anticholinergics are not commonly used to treat Parkinson’s. They Procyclidine might help with some Parkinson’s yy Kemadrin (tablets, syrup) symptoms but can make others worse. yy Kemadrin (solution for injection) They can be used in younger people Trihexyphenidyl (benzhexol) with a noticeable tremor. But older yy Unbranded (tablets, syrup) people who take anticholinergics are more likely to experience How do anticholinergics side effects such as confusion work? and hallucinations. Anticholinergics block a chemical If you take them for a number messenger called acetylcholine of years, they can be quite which is found in your brain and difficult to stop and some people body. It helps to send messages in the brain as well as from your nerves to your muscles.

43 experience withdrawal symptoms. Parkinson’s and may have only a mild effect. Benefits of anticholinergics Memory problems Improving Parkinson’s symptoms Anticholinergics are not often given Some anticholinergics may help to people with Parkinson’s because with tremor with some Parkinson’s they can cause memory problems symptoms when other medication or make existing problems worse. is no longer working. This can happen at any age, but particularly for older people.

Anticholinergics may help with If you’re taking anticholinergics, rigidity, slowness of movement, your specialist or Parkinson’s nurse tremor, speech and writing must monitor you regularly. difficulties, gait, sweating, involuntary movements of

the eyes and feeling depressed. Other side effects Most of the side effects Improving sialorrhoea and of anticholinergics are rare, drooling but it is important to know Anticholinergics can reduce the what to look out for. flow of saliva in your mouth which may be helpful if you experience For the full range of side effects, drooling or produce too much see the patient information saliva (sialorrhoea). However, leaflet that comes with your anticholinergics can also lead to anticholinergics medication. a dry mouth so discuss whether See the section on side effects of this option is right for you with Parkinson’s drugs to find out more. your health professional. Some of the other possible side effects you may experience with Risks and side effects anticholinergics include: of anticholinergics yy mental health issues Limited effect on most Parkinson’s symptoms yy eye problems Anticholinergics are not a first yy constipation choice for the treatment of yy skin reactions

44 yy trouble urinating Alternatively, it is available as a syrup. These options are useful Procyclidine (Kemadrin) if you have difficulty swallowing Procyclidine (Kemadrin) is a type tablets. They can also release your of anticholinergic medication. medication more quickly.

It may be helpful if you experience Procyclidine (Kemadrin) can muscle spasms (dystonia) which be taken with levodopa and cannot be controlled with other amantadine medication. Your medication. It may also help to specialist will be able to discuss control more complex Parkinson’s whether this option is right for you. symptoms such as delusions (seeing, hearing, feeling, smelling Trihexyphenidyl or tasting something that isn’t (also called benzhexol) really there). Trihexyphenidyl or benzhexol is a type of anticholinergic medication. Taking procyclidine (Kemadrin) The most recent and complete It may be helpful if you experience information on your specific drug will muscle spasms (dystonia), tremor be on your patient information leaflet or excessive saliva production that comes with your medication (sialorrhoea) which cannot be packet. Always read it carefully controlled with other medication. before you start your treatment. Taking trihexyphenidyl medication For detailed information you should You will usually take trihexyphenidyl follow the advice of your healthcare medication three or four times professional about how to take a day at mealtimes. If you find procyclidine (Kemadrin) so that it that it causes you to experience works well for your Parkinson’s. a dry mouth your specialist may recommend you take You will usually take Kemadrin trihexyphenidyl before your meal. three times a day. Your specialist or Parkinson’s nurse can increase your This can make you feel sick. Instead dose until it controls your symptoms. you can take your medication after you have finished eating. If you do There is also the option to have this, you may notice an increased procyclidine (Kemadrin) as an thirst. Water, peppermint or injection into your muscles. 45 chewing gum can help this issue. used to treat Parkinson’s and Your specialist will prescribe a small most people will experience a mild dose of trihexyphenidyl at first improvement in their symptoms. and this will be increased until your symptoms are controlled. See the section on the risks and side effects of anticholinergics You can take trihexyphenidyl with to find out more. your levodopa medication. Your specialist will be able to discuss For the full range of side effects, whether this option is right for you. see the patient information leaflet that comes with your medication. Benefits and risks of procyclidine and trihexyphenidyl medication Trihexyphenidyl (or benzhexol) and procyclidine (Kemadrin) is sometimes

46 PARKINSON’S DRUGS AND HOW TO PRONOUNCE THEM

This list shows the class of Parkinson’s drug in capital letters, the unbranded name of the drug in bold and the brand name in bullet points. The pronunciation of each drug is written in blue.

This list is correct as of July 2019.

This list doesn’t show the order in which medications are prescribed. Everyone with Parkinson’s will have a drug regime that is right for them.

LEVODOPA LE-vo-do-pa Co-beneldopa koh–BEN–el –DOH-puh yy Madopar (capsules, dispersible tablets) MAH-doh-par yy Madopar CR (controlled release capsules) Co-careldopa koh–KA-rul-DOH-puh yy Caramet CR KA-ra-met yy Lecado (modified release tablets) LEH–kah–doh yy Half Sinemet CR (controlled release tablets) SIN-nuh-met yy Sinemet (tablets) yy Sinemet Plus (tablets) yy Sinemet CR (controlled release tablets) yy Duodopa (intestinal gel) DO-o-doh-puh  47 Co-careldopa and entacapone koh–KA-rul-DOH-puh and en-TA- kuh–pone yy Stalevo/Sastravi (tablets) sta-LE-voe / Sa-STRA-ve yy Stanek (tablets) STA-neck DOPAMINE AGONISTS DOH-puh-meen-A-gu-nists Pramipexole PRA-me-PEK-sol yy Mirapexin (tablets) MIH-ruh-pek-sin yy Mirapexin (prolonged release tablets) yy Pipexus (modified release tablets) pi-PEX-us yy Glepark (tablets) GLE-park yy Oprymea (tablets) o-PRY-mea yy Zentiva (prolonged release tablets) zen-TIVA

Ropinirole roh-PIH-nih-roll

yy Adartrel (tablets) ad-AR-trul yy Ralnea XL (prolonged release tablets) RAL–nee– a yy Requip (tablets) RE–kwip yy Requip XL (prolonged release tablets) yy Spiroco XL (prolonged release tablets) SPY-roh-koh yy Ipinnia XL (prolonged release tablets) i-PIN-nia yy Raponer XL (prolonged release tablets) ra-PONE-nuh yy Ropilynz XL (prolonged release tablets) RO-pill-ins  48 Rotigotine ra-TIH-goh-teen yy Neupro (skin patch) NEW-pro Apomorphine A-poh-MOR-feen yy Apo-go pre-filled pen for intermittent injection A-poh–go yy Dacepton cartridge for intermittent injection (can be used with a re-usable pen) DAH-sep-ton yy Apo-go pre-filled syringe for infusion (can be used with a continuous infusion pump) yy Dacepton vial (can be used with a continuous infusion pump) Bromocriptine bro–mo–KRIP-teen We have not included information about bromocriptine because this medication is rarely used. yy Parlodel (tablets, capsules) PAR-luh-del Cabergoline ka–BER–go– leen We have not included information about cabergoline in this booklet because this medication is rarely used. yy Cabaser (tablets) ka-BA-suh yy Dostinex (tablets) DOS-ti-nex Pergolide PER-guh-lied We have not included information about pergolide in this booklet because this medication is rarely used.   49 MAO-B INHIBITORS M-A-O-B-in-HIH-bi-tuz Rasagiline ra-SAH-ji-leen

yy Azilect (tablets) A-zih-lekt Selegiline seh-LEH-ji-leen yy Eldepryl (tablets) EL-duh-pril yy Zelapar (tablets that dissolve on the tongue) ZEH-luh-par Safinamide sa-FIN-a-mide yy Xadago (tablets) ZA-DA-go COMT INHIBITORS KOMT in-HIH-bit-ers

Entacapone en-TA-kuh–pone yy Comtess (tablets) KOM–tess Co-careldopa and entacapone koh–KA-rul-DOH-puh and en-TA- kuh–pone yy Stalevo/Sastravi (tablets) sta-LE-voe / Sa-STRA-ve yy Stanek (tablets) st-A-neck   50 yy Tolcapone TOLL-kuh-pone We have not included information about Tolcapone in this booklet because this medication is rarely used. yy Tasmar (tablets) TAZ–mar Opicapone oh-PEE-kuh–pone

yy Ongentys (tablets) on-GEN-tees Amantadine (capsules, syrup) a–MAN–ta–deen ANTICHOLINERGICS anti-colin-ER-gics Procyclidine pros-I-claire-deen yy Kemadrin (tablets, syrup) ka-MAY-drin yy Kemadrin (solution for injection) Trihexyphenidyl (benzhexol) (tablets, syrup) TROX-i-fen-i-dril BEN-ex-ol Sometimes, new Parkinson’s medication is produced, or stopped. The most recent list of treatments is available at parkinsons.org.uk/drug-treatment   51 NOTES

......

......   52 USEFUL CONTACTS USEFUL GP name and phone number name and phone nurse number Parkinson’s name and phone specialist number Consultant contact emergency of In case contact emergency of In case MY DETAILS MY Name birth of Date Address numberPhone and email Email MEDICATION RECORD MEDICATION   53 DBS number is The serial unit. a DBS I have and phone number nurse is DBS My and phone number specialist DBS is My Apomorphine Apomorphine Name and phone number of the person Name person and phone the number of pump is my administers who my of time and start stop rate Flow pump is are I use that Apomorphine devices vile, needle pen, syringe, of (Name cartridge?)   54 Notes Times of doses Times Dose Medication name Medication Date My medication My   55 Notes Times of doses Times Dose Medication name Medication Date My medication My   56 Notes Times of doses Times Dose Medication name Medication Date My medication My   57 Notes Times of doses Times Dose Medication name Medication Date My medication My  58 more information and support

Reporting a side effect Parkinson’s nurses The Medicines and Healthcare Parkinson’s nurses provide expert Products Regulatory Authority advice and support to people with (MHRA) is the government body Parkinson’s and those who care for that makes sure that drugs work them. They can also act as a liaison and are safe. It is keen to receive between other health and social feedback about medication care professionals to make sure side effects. your needs are met.

To report a side effect, you should Parkinson’s nurses may not be complete a Yellow Card form, available in every area, but your available from your pharmacist, GP or specialist can tell you about GP, specialist or via the Yellow Card local services. information service 0808 100 3352. You can find out more at parkinsons.org.uk/nurses You can also complete this form online, or download and print it Information and support from yellowcard.mhra.gov.uk. from Parkinson’s UK Speak to your pharmacist, GP, You can call our free confidential specialist or Parkinson’s nurse helpline for general support and if you need any help filling in information. Call 0808 800 0303 this form. (calls are free from UK landlines and most mobile networks) or email You can also report any side effects [email protected] from your Parkinson’s medication directly to your GP, specialist or Our helpline can also put you Parkinson’s nurse. in touch with one of our local advisers, who provide one-to-one information and support to anyone

 affected by Parkinson’s. They can 59 also provide links to local groups and services.

Our website has information about your local support team and how to contact them at parkinsons.org.uk/localtoyou

You can find details of our local groups and your nearest meeting at parkinsons.org.uk/localgroups

You can also visit parkinsons.org.uk/forum to chat to other people with similar experiences on our online discussion forum.

60                  1. Please choose the option that best fits you. [email protected] email or Parkinson’s 215 UK, Vauxhall Bridge Road, London SW1V 1EJ as possible. Please return to Information Content team, will help us ensure our resources are as useful and easy to understand youDo have any feedback about this information? Your comments treatmentsDrug for Parkinson’s (PKB013/2019) 3. it answered Has your all questions? 2. Where did you get this information from? 4. How easy was it to understand? Other (please specify) to Call the helpline Parkinson’s local UK adviser Parkinson’s nurse GP Other (please specify) I’m aprofessional working with people with Parkinson’s Ihave afriend or family member with Parkinson’s Icare for someone with Parkinson’s Ihave Parkinson’s and was diagnosed in Not sure Easy Very easy Partly Yes, mostly Yes, completely

       Ordered directly from us Parkinson’s local UK group Specialist Very difficult Quite difficult Not atall Not sure . Thank you!. 

, 5. Has it helped you manage your condition better, or make choices that have improved your life in some way?  It helped a lot  It didn’t help  It helped a little  It made things worse  No change

6. What is your ethnic background?*  Asian or Asian British  Mixed  Black or Black British  White British  Chinese  White other  Other (please specify)

*We ask about your ethnicity to ensure our information is reaching a broad range of people. However, this question is optional.

Want to hear more from us?  I would like a response to my feedback  I would like to be a member of Parkinson’s UK  I’m interested in joining the Information review group, to offer feedback on Parkinson’s UK information

If you’ve answered yes to any of these options, please complete your details below.

Name Address Email Telephone

How would you prefer us to contact you?  Email  Post  Phone We will not pass on your details to any other organisation or third party. To find out more, read our privacy policy atparkinsons.org.uk/termsandconditions  Thank you to everyone who Services team on 0800 138 6593 contributed to or reviewed this or visit our website at parkinsons. booklet: org.uk/donate. Thank you. Lee Kieft, Parkinson’s Nurse, Our information Lewisham and Greenwich All of our most up-to-date Hospital NHS Trust information is available at Liz Scott, Parkinson’s Nurse, parkinsons.org.uk/ Parkinson’s UK Helpline informationsupport If you’d prefer to read one of Shelly Jones, Clinical Pharmacy our printed leaflets or booklets, Teamleader, Neurosciences, find out how to place an order King’s College Hospital at parkinsons.org.uk/ Thanks also to our information orderingresources or by calling review group and other people 0300 123 3689. affected by Parkinson’s who provided feedback. We make every effort to ensure that our services provide current, All of the photographs in this unbiased and accurate information. booklet feature either people We hope that this will add to any affected by Parkinson’s, health and professional advice you receive and social care professionals involved in help you to make any decisions you caring for people with Parkinson’s may face. Please do continue to or Parkinson’s UK staff. Thank you talk to your health and social care to everyone involved for letting us team if you are worried about any use their photograph. aspect of living with Parkinson’s. Can you help? If you’d like to find out more about At Parkinson’s UK, we are totally how we put our information dependent on donations from together, including references and individuals and organisations to the sources of evidence we use, fund the work that we do. There please contact us at are many ways that you can help us [email protected] to support people with Parkinson’s. If you would like to get involved, please contact our Supporter

63 Every hour, two people in the UK are told they have Parkinson’s – a brain condition that turns lives upside down, leaving a future full of uncertainty.

Parkinson’s UK is here to make sure people have whatever they need to take back control – from information to inspiration.

We want everyone to get the best health and social care. So we bring professionals together to drive improvements that enable people to live life to the full.

Ultimately, we want to end Parkinson’s. That’s why we inspire and support the international research community to develop life-changing treatments, faster. And we won’t stop until we find a cure.

Together we can bring forward the day when no one fears Parkinson’s. Parkinson’s UK 215 Vauxhall Bridge Road London SW1V 1EJ Free confidential helpline0808 800 0303 (Monday to Friday 9am–7pm, Saturday 10am–2pm). Interpreting available. NGT Relay 18001 0808 800 0303 (for use with smart phones, tablets, PCs and other devices). For more information see www.ngts.org.uk [email protected] parkinsons.org.uk Thank you to Ethypharm for their support with the costs of printing this booklet. Ethypharm had no editorial control over the content.

Order code: PKB013 Last updated July 2019. We review our information within three years. Please check our website for the most up-to- date versions of all our information.