Drug and Non-drug Treatments to Manage PD Symptoms

At the present time, there is no widely accepted medical “standard of care” for treating a patient with PD, and there is no cure or treatment to slow the disease progress. Treatment approaches include medication, surgical therapy, and lifestyle modifications such as rest and exercise, physical therapy, occupational therapy, and speech therapy. Treatment approaches that collectively utilize drug with non-drug treatments tend to optimize medication results. Individualized care is usually directed at treating the most vexing symptoms with the least amount of adverse effects.1,39,40

Vast arrays of pharmacological options are available to manage symptoms associated with PD. Guidelines that define exactly what drugs to use at various stages of the disease do not exist. Studies have shown initiating drugs relative early in the disease process provides the best prognosis for maintaining long-term motor function.41 Levodopa, an amino acid that converts to dopamine, is the most commonly prescribed drug intervention. It is considered the “gold-standard” because it has been shown to be the most effective drug for treating PD symptoms.1,41,42 Historically, doctors have utilized a sustained positive response to dopaminergic medications to verify the initial diagnosis of idiopathic PD.1,43 As the PD progresses a combination of levodopa therapy, dopamine agonists, MAO-B inhibitors, and/or COMT inhibitors are commonly prescribed due to individuals becoming less responsive to levodopa.1,44 One concern with levodopa therapy is the development of levodopa-induced dyskinesias and dystonia. Dental providers must be aware that these movements can affect the muscles of the head, face, tongue, and muscles of mastication.39,40

A comprehensive list of medications to manage PD symptoms is listed in Table 3. This table includes information about medication indications, interactions (with other drugs, alcohol, supplements, antacids, and foods), and common adverse effects. Ten of the medications can be used to initiate symptomatic therapy at the beginning stages of the disease. They can be used alone or in conjunction with other medications. Some of the most common adverse effects include nausea, orthostatic hypotension, dyskinesia, dizziness, hallucinations, and various forms of pain.45-49 Common oral adverse effects include xerostomia, dry throat, bruxism, gingivitis, tongue edema, abnormal taste and glossitis.7,22,45,46 There are many classes of drugs that interact with PD medications: anti-psychotic, anti-emetic, anti-hypertensive, anti-depressant, narcotic/analgesic, muscle relaxant, decongestant, and cough suppressant. These drugs should be avoided because they alter the brain’s dopamine system and/or chemically interact with PD medications. Drug interactions can increase PD symptoms and undesirable side effects. Sedatives may have an additive effect when prescribed to patients who are taking antiparkinsonian drugs. Patients who are taking pramipexole (Mirapex®) should not be prescribed erythromycin. When patients are taking dopamine agonists or COMT inhibitors, local anesthesia should be used with caution.50,51 Some of the dopamine agonists and all of the COMT inhibitors can potentially interact with epinephrine.50 Entacapone (Comtan®) may delay metabolism of epinephrine and levonordefrin. This could increase the length of time that cardiovascular stimulation occurs.51 Dental providers should consider dosage and time interval before administering multiple carpules of local anesthesia with epinephrine.

Table 3. Medications used for PD-related symptom management.45-49
Name of MedicationIndicationsCommon Interactions with Drugs, Alcohol, Supplements, Antacids, and FoodsCommon Adverse Effects
*effects that affect the provision of oral health care in bold
Carbidopa/Levodopa Therapy
*drugs that metabolize into dopamine (dopamine replacement)
Duopa™
(Carbidopa/Levodopa)
A new approach to the administration of carbidopa and levodopa for the treatment of motor fluctuations for people with advanced PD.Interacts with antacids, anti-seizure drugs, anti-hypertensives, anti-depressants, high protein foods, and MAO inhibitors Complication of device insertion, nausea, constipation, incision site erythema, dyskinesia, depression, post procedural discharge, peripheral edema, hypertension, upper respiratory tract infection, oropharyngeal pain, atelectasis, confusional state, anxiety, dizziness, hiatal hernia, and sleepiness or suddenly falling asleep without warning
Parcopa®
(Carbidopa/Levodopa)
First course of treatment; converts to dopamine to manage major symptoms; helpful for patients with swallowing difficultiesInteracts with antacids, anti-seizure drugs, anti-hypertensives, anti-depressants, and high protein foodsLow blood pressure, nausea, confusion, dyskinesia, xerostomia, dizziness, orthostatic hypotension, taste alteration, bruxism, heartburn
Rytary™
(Carbidopa/Levodopa)
A new approach to the administration of carbidopa and levodopa for the treatment of PD, post-encephalitic parkinsonism, and parkinsonism that may follow carbon monoxide intoxication or manganese intoxication Interacts with MAO inhibitors, Dopamine D2 receptor antagonists, and iron saltsNausea, dizziness, headache, sleeplessness, abnormal dreams, xerostomia, dyskinesia, anxiety, constipation, vomiting, and orthostatic hypotension
Sinemet®
(Carbidopa/Levodopa)
First course of treatment; converts to dopamine to manage major symptoms; CR may prolong effectivenessInteracts with antacids, anti-seizure drugs, anti-hypertensives, anti-depressants, and high protein foodsLow blood pressure, nausea, confusion, dyskinesia, xerostomia, dizziness, orthostatic hypotension, taste alteration, bruxism, heartburn
Stalevo®
(Carbidopa/Levodopa/
Entacapone)
Second course of treatment; entacapone blocks COMT enzyme to prolong effectiveness of levodopaInteracts with antacids, anti-seizure drugs, anti-hypertensives, anti-depressants, high protein foods, MAO inhibitors, and high doses of selegilineDyskinesia, nausea, diarrhea, hyperkinesia, abdominal pain, dizziness, harmless discoloration of saliva, orthostatic hypotension, taste alteration, bruxism, heartburn
Dopamine Agonists
*drugs that stimulate parts of the brain influenced by dopamine
APOKYN™ injection
(apormorphine hydrochloride)
Adjunct to levodopa therapy to treat “off” periods5HT3 agonists, antihypertensivesNausea, vomiting, low blood pressure, sleepiness, dyskinesia, hallucinations, chest pain, use vasoconstrictor with caution (may cause torsade de pointes/ long QT)
Mirapex®
(Pramipexole)
First course of treatment alone or with levodopa in early-stage idiopathic PD; mimics dopamine to manage major symptomsSedatives and tranquilizers; metocipramide, thiozanthenes, cimetidine, phenothiazines, butyrophenones, erythromycin Arthritis, chest pain, nausea, low blood pressure, sleep disturbances, sedation, xerostomia, dysphagia, orthostatic hypotension
Mirapex® ER
(Pramipexole dihydrochloride extended release)
For the treatment of the signs and symptoms of early PDDopamine antagonists, erythromycinSleepiness, nausea, dizziness, fatigue, hallucinations, muscle spasms, peripheral edema, xerostomia, dysphagia, orthostatic hypotension
Neupro®
(Rotigotine Transdermal System)
First course of treatment alone or with levodopa in early-stage idiopathic PD; for advanced stage idiopathic PD; mimics dopamine to manage major symptomsAllergic type reactions (including anaphylactic symptoms) especially in individuals sensitive to sulfitesNausea, application site reactions, sleepiness, dizziness, headache, vomiting, sleep attacks, insomnia, xerostomia, orthostatic hypotension
Parlodel®
(Bromocriptine)
First course of treatment alone or with levodopa; mimics dopamine to manage majors PD symptomsAlcohol, anti-psychotics, blood pressure lowering medicationsLow blood pressure, nausea, edema, confusion, xerostomia, depression, headaches, use vasoconstrictor with caution (bromocriptine has vasoconstricting effects), orthostatic hypotension
Requip®
(Ropinirole)
First course of treatment alone or with levodopa; mimics dopamine to manage majors PD symptomsAlcohol, anti-depressants, Cipro®, anti-psychotics, benzodiazepinesAbdominal pain, sleep disturbances, nausea, increase or decrease in blood pressure, sedation, xerostomia or increased salivation
Requip® XL™
(Ropinirole extended release)
First course of treatment alone or with levodopa; mimics dopamine to manage majors PD symptoms; 24 hours of continuous medication delivery to keep blood levels balancedInhibitors or inducers of CYP1A2 higher doses of estrogen, usually associated with hormone replacement therapy, dopamine antagonistsNausea, dizziness, drowsiness, headache, dyskinesia, abdominal pain/discomfort, hallucination, increase or decrease in blood pressure and heart rate, xerostomia or increased salivation, may increase the side effects of levodopa such as gambling, sexual or other intense urges
MAO-B Inhibitors
(blocks an enzyme in the brain that breaks down levodopa)
Azilect®
(Rasagiline)
Initial monotherapy when signs and symptoms if PD appear, adjunct to levodopaNarcotic painkillers, anti-depressants, decongestants, excessive amounts of tyramine-rich foods (draft beer, red wine, aged cheese) are not recommendedAvoid vasoconstrictors due to possibility of hypertensive episodes, xerostomia causing discomfort and dental disease, orthostatic hypotension
Carbex®
Elderpryl®
(Selegiline)
Tertiary medication to control metabolism of dopamineAnti-depressants, narcotic painkillers, decongestantsAgitation, insomnia, hallucinations
Zelapar®
(Selegiline HCL)
Adjunct to levodopa in patients with significant “off” periods; helpful for patients with swallowing difficultiesAnti-depressants, narcotic painkillers, decongestantsDizziness, nausea, pain, headache, insomnia, rhinitis, dyskinesia, back pain, stomatitis, dyspepsia, xerostomia causing discomfort and dental disease
Anticholinergics
(decrease the activity of acetylcholine-a neurotransmitter that regulates movement)
Cogentin®
(Benztropine mesylate)
Secondary medication to ease tremors and restore balance Anti-histamines, Propulside®, Haldol®, Thorzaine®, Symmetrel®, Clozaril®, alcoholConfusion, hallucinations, nausea, blurred vision, xerostomia, urinary retention, nervousness
Artane®
(Trihexyphenidyl HCL)
Secondary medication to ease tremors and restore balanceAnti-histaminesConfusion, hallucinations, nausea, blurred vision, xerostomia causing discomfort and dental disease, urinary retention, nervousness
COMT Inhibitors
(prolong effect of levodopa by blocking its metabolism)
Comtan®
(Entacapone)
Secondary medication that prolongs the effectiveness of levodopaMAO inhibitorsAbdominal pain, back pain, constipation, nausea, diarrhea, blood in urine, orthostatic hypotension, use vasoconstrictors with caution
Tasmar®
(Tolcapone)
Tertiary medication for motor fluctuations; limited in use to individuals who have exhausted other treatment optionsMAO inhibitorsAbdominal pain, back pain, constipation, nausea, diarrhea, blood in urine, liver failure, xerostomia, use vasoconstrictors with caution
Other Medications
Symmetrel®
(Amantadine)
Secondary medication for tremors and muscle rigidityCogentin®, Disipal, Sinemet, Artane, amphetamines, alcoholGI problems, xerostomia, orthostatic hypotension, dizziness, weakness, skin blotches
Exelon®
(Rivastigmine tartrate)
Dementia associated with PDNoneNausea, vomiting, loss of appetite, weight loss
Northera™
(Droxidopa)
Treatment of symptomatic neurogenic orthostatic hypotensionAgents that increase blood pressure; norepinephrine, ephedrine, midodrine, and triptans; Dopa-decarboxylase inhibitors may require dose adjustmentsHeadache, dizziness, nausea, hypertension, and fatigue