Ask Dr Z - SEPDA

srh_pres · Site Admin Joined: 07 Jan 2007 Posts: 35

Question #58:
"My psychiatrist has prescribed requip for -off label- mood elevation. Have you heard of this use? "

Answer #58:
Pramipexole, or Mirapex, is a dopamine agonist that has been shown to treat depression, off-label. This has been demonstrated in controlled studies. There is less evidence with ropinirole or Requip. The question is whether you have PD, and your psychiatrist is trying to treat your mood while treating the PD symptoms. You may want to ask him if this is his strategy. Have you failed conventional antidepressants?
Dr. Z

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Question #57:
"I have jaw/lower lip and left hand tremors. I have tried mirapexin and requip also half beta. None of which have helped stop or ease my tremors. I am currently on artane 3x5mg per day. little or no ceasation of the tremors. I can live with all the other pd symtoms but my tremors really get me down. Help please?"

Answer #57:
Tremor that is refractory to medication may be treated by surgery, namely the Deep Brain Stimulator (DBS) in the VIM (ventral intermediate nucleus of the thalamus). Most university centers have surgical programs that could evaluate your tremor for this procedure. Medtronics is the company that produces the device. With the DBS, an electrode is implanted in a region of the brain, and a wire is attached to this electrode and passed down the neck to an area near the clavicle. Then a pacemaker-like device is surgically inserted near the clavicel. The patient is awake for most of this procedure, and pending complications, usually is discharged from the hospital fairly quickly. About three weeks later, the device is programmed to reduce the tremor. The procedure is highly effective in treating tremor. However, there are contraindications to the procedure, such as dementia. Please contact your neurologist to discuss the procedure.
Dr. Z

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Question #56:
"Does the shakes ever quit after the patient quits taking haldol?"

Answer #56:
Parkinsonism that occurs after neuroleptics usually resolves, but can take many months (sometimes 6 months). Neuroleptics such as haldol can cause other problems, such as tardive dyskinesia as well. These medications need to be used cautiously, especially in elderly patients. It is often prudent to use one of the new atypical antipsychotic medications, such as quetiapine and clozapine.
Dr. Z

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Question #55:
"My 80 y/o Dad has been on Sinemet for over 2 years. We replaced it with Requip 0.25mg, 3 times a day after decreasing the Sinemet over a 2 week period. His stiffness, immobility and speech have gotten much worse since then. Comments please."

Answer #55:
The dose of Requip you describe is relatively low. I'm not surprised that the Parkinson's disease symptoms have worsened. You didn't say why your father was taken off Sinemet. Was he suffering from side effects from Sinemet? Although there are some concerns about the early use of Sinemet due to motor fluctuations, the early use of Sinemet in patients who are elderly is frequently a very effective way to reduce the symptoms of Parkinson's disease. In addition, dopamine agonists (Mirapex, Requip) can cause difficulties with thinking, and can be expensive for elderly patients. I would consult with your physician again about why Sinemet was stopped. If side effects were not a problem, you may want to consider restarting it.
Dr. Z

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Question #54:
"My father has Parkinson's disease. I would like to know your opinion of glutathione treatment and if you know when the study about it at the Univ. of S. Florida will be completed? Also, do you recommend nutritional supplements to raise gluathione levels that then are better able to address oxidative stress?"

Answer #54:
The study of glutathione treatment here at the University of South Florida is still on-going. It is a controlled trial, and requires coming to the office here in Tampa 3 times a week for one month. However, there is no cost to receive the treatments if you are part of the study. Although glutathione has been used to treat Parkinson's disease sporadically by some physicians, the only way to truly assess its worth as therapy is to perform a controlled study such as the one at USF. Please contact Summer Wolfrath at 813-844-4455 if you are interested in participating.
Dr. Z

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Question #53:
"I just read the Report of the Quality Standards Subcommittee of the American Academy of Neurology that I believe you helped write and which was published April 2, 2006. I do not understand why the article did not address glutathione and its precursors (e.g., NAC) as a nutritional supplement in either of the 2 questions your group addresssed? Also, the article did not mention the study article from 1996 from Italy which used iv Glutathione beneficially. Was that because the study was not conducted in US? "

Answer #53:
The reports from the Quality Standards Subcommittee from the American Academy of Neurology examine research in an evidence-based manner. This type of evidence-based research differs from reviews or opinion articles by classifying research according to stringent criteria. Double-blind, placebo-controlled trials get the highest rating, while open-label trials and case reports get lower ratings.
USF is conducting a double-blind, placebo-controlled trial to assess is glutathione is beneficial to PD patients. One open-label trial of glutathione would result in a Level U recommendation.
It's important to remember that the paper you cited by the American Academy of Neurology rates "evidence". It doesn't mean that treatments such as glutathione don't work, but that the research associated with glutathione did not command the same grade as other therapies that were tested with double-blind trials. The article grades the level of evidence, and then gives a recommendation. With time and hopefully more research, these recommendations may change.
I have forwarded your question to the lead author of the practice parameter, Dr. Oksana Suchowersky, for her thoughts.
Dr. Z

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Question #45:
"I understand that only a small percentage of PD is presumed to be caused by defective or missing genes. Why then is so much research being conducted into a genetic cause of PD?"

Answer #45:
Coming soon.
Dr. Z