Feb 03 2010

Cougar Rx Corner

Published by cate

Some articles are written by 4th year Doctor of Pharmacy students at Washington State University’s College of Pharmacy, Spokane, WA while others are written by Dr Lindy Wood, Pharm. D. They are presented here as general information only and not intended to diagnose or treat any condition. As always, talk with your physician and/or pharmacist  about your medications.

Failure to Launch: Blood Pressure Plunges in Parkinson’s Disease

By Darren Shimanuki, PharmD Candidate 2011

Normally, when a person stands up from sitting or lying down, the body responds in a variety of ways to maintain adequate blood supply to the brain.  These responses are regulated by the autonomic nervous system, which controls involuntary functions including those of the heart, blood vessels, and intestines.  For instance, the autonomic nervous system changes how fast the heart beats when running away from a bear versus sitting and watching television.

In people with Parkinson’s disease, this “autonomic response” is impaired or diminished.  As a result, people with Parkinson’s may experience a dramatic plunge in blood pressure upon sitting up or standing.  This phenomenon is called orthostatic hypotension [ortho-: standing; -static: stationary; hypo-: low; -tension: blood pressure] (A.K.A. postural hypotension).  Your doctor may want to check your blood pressure in both a sitting and a standing position to see if this is occurring.

Symptoms typically last a few seconds to minutes.  In mild cases, symptoms include dizziness, light-headedness, blurred vision, nausea, and headache.  In severe reductions of blood flow to the brain, people may faint or briefly lose consciousness (syncope).  Overall, the major concern of this occurrence is the elevated risk of falls and consequent risk of bone fracture.

Orthostatic hypotension has many different causes in addition to Parkinson’s disease.  It is a very common side effect for different types of medications, including drugs used to treat Parkinson’s disease, such as levodopa-carbidopa (Sinemet®), apomorphine (Apokyn™), amantadine (Symmetrel®), ropinirole (Requip®), and pramipexole (Mirapex®).  It also commonly occurs with blood pressure-lowering medications such amlodipine (Norvasc®), hydrochlorothiazide (Microzide®) and metoprolol (Lopressor®, Toprol XL®), among others.  It is important to note that someone with hypertension (hyper- : high) can still have orthostatic hypotension.  Ask your doctor and pharmacist if you think your medication is contributing to orthostatic hypotension.

Certain activities such as alcohol consumption, exercise, prolonged bed rest, and eating a heavy meal all raise the risk of orthostatic hypotension.  Other medical conditions that increase this risk include dehydration, diabetes, infection, low blood volume (e.g., anemia, internal bleeding), and other neurological disorders such as Shy-Drager syndrome, and multiple system atrophy.

Treatment options for orthostatic hypotension depend on the underlying cause.  If it is a side effect of a medication, adjusting the dose or administration time may lessen or even reverse the effect (do not attempt this without your doctor’s supervision).  There are medications used to treat low blood pressure.  Ask your doctor it they are appropriate.

Maintaining adequate hydration is always important (minimum of six 8oz. cups per day, total 48oz.).  Other interventions include increased dietary salt intake, wearing compression stockings, and sitting and standing slowly when changing positions.  Talk to your health care provider about your concerns, and discuss possible ways to manage orthostatic hypotension.

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Azilect® (Rasagiline): Say Cheese!

by Marjan Bigverdi, Pharm.D Candidate 2010

Azilect® (Rasagiline) is a once-daily medication used in the treatment of Parkinson’s disease (PD). Over time, PD causes loss of more and more dopamine in the brain. As much as 60% to 80% of dopamine could be lost by the time PD is diagnosed. Azilect® works by blocking the breakdown of dopamine in the brain and is indicated for the treatment of the signs and symptoms of PD as initial therapy in early phases of the disease by itself and in combination with levodopa/carbidopa (Sinemet®).

If you are currently taking Azilect®, you might have been advised by your doctor or pharmacist to avoid certain types of foods and beverages to prevent a possibly dangerous rise in your blood pressure. These are any foods or drinks that have high amounts of a substance called tyramine. Tyramine-containing foods are a variety of aged cheeses, aged or fermented meats, pickled goods, soybean products, and all varieties of tap beer.

Based on a new study reviewed by the Food and Drug Administration (FDA) in December of 2009, the dietary restrictions of tyramine containing foods with Azilect® use have been removed. According to this study, the combination of Azilect® [when taken at recommended manufacturer dose (0.5mg and 1mg)] with tyramine containing foods did not cause a dangerous increase in blood pressure. Although you no longer need to refrain from consuming the food items mentioned above, the manufacturer still recommends that all patients on Azilect® avoid foods that have very high amounts of tyramine (i.e., > 150 mg), such as concentrated yeast extracts (e.g., Marmite) or Stilton aged cheese. This is especially important for patients who take Azilect® in conjunction with levodopa or Sinemet®. Combined use of these medications can put you at higher risk for increased blood pressure. You should always contact your healthcare provider if you experience severe headache, shortness of breath, heart palpitations, chest pain or other similar symptoms while you are taking Azilect®.

Moreover, according to this new study, patients who take Azilect® can now safely take some medications that were previously thought to cause drug interactions. These medications mainly belong to the cough-and-cold category and include pseudoephedrine (Sudafed®), phenylephrine and ephedrine. Also, patients can now undergo surgeries using general or local anesthesia without worries about possible drug interactions and no longer need to stop their Azilect® before surgery. This is also true about medications used to treat adrenal gland tumors in patients with a condition called Pheochromocytoma. Based on the recent findings, patients on Azilect® can go on with treatments for adrenal gland tumors without worries about possible complications.

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What Cough and Cold Medicines Can You Take?

by Jessica Carpenter, Pharm.D. Candidate 2010

A reasonable concern for those people with Parkinson’s disease is whether or not over-the-counter (OTC) medications can safely be taken without interacting with their Parkinson’s medications or worsening their Parkinson’s symptoms. There are numerous cough and cold ingredients sold under different brand names and in different formulations which can make selecting a product very confusing.

Dextromethorphan is a cough suppressant and common ingredient in many cough and cold medications, either by itself or in combination with other ingredients. Common brands that often contain dextromethorphan are Delsym, Vicks, Robitussin DM, Theraflu, and Triaminic, as well as other generic store brands. People taking the MAO-B inhibitors selegiline (Eldepryl) or rasagiline (Azilect) for Parkinson’s disease should not take dextromethorphan. If you are not sure if a product contains dextromethorphan or not, please ask your pharmacist and let them know what medications you take for Parkinson’s disease.

There are two common oral decongestants that are found in cough and cold medicine to reduce a stuffy, runny nose. Pseudoephedrine (Sudafed) and phenylephrine (Sudafed PE) are oral decongestants used for nasal congestion associated with allergies or the common cold. Pseudoephedrine is available for purchase at the pharmacy counter only. There is a limit to how much a person can legally buy at one time and how often. Despite earlier warnings that MAO-B inhibitors cannot be used with certain OTC medications due to the risk of an increase in blood pressure, recent studies have shown that Azilect (rasagiline) is safe to use with decongestants such as pseudoephedrine or phenylephrine. The other MAO-B inhibitor, selegiline is similarly considered to be safe. If a decongestant is needed, nasal sprays such as Afrin can also safely be used with any Parkinson’s medications, but to avoid worsening congestion, limit use to a maximum of 3 to 5 days.

Guaifenesin is an expectorant cough medicine, which means it thins mucous and phlegm and assists in bringing up mucous from the throat and lungs. Guaifenesin can be found in numerous cough and cold products, more common ones being Robitussin, Mucinex, Q-Tussin, as well as many other combination products. Guaifenesin is considered safe when combined with any of the available Parkinson’s medications.

Many cold and allergy preparations contain antihistamines. They are often used for runny nose, sneezing, itchy or watery eyes, or allergic reactions like hives. Examples of these are diphenhydramine (Benadryl, Tylenol PM, Advil PM), chlorpheniramine (Chlor-Trimeton), loratadine (Claritin), cetirizine (Zyrtec), and numerous other combination products of different names. These are all considered safe to take with Parkinson’s medications, although some have more side effects than others, such as drowsiness, so it’s good to ask a pharmacist for a recommendation.

Many cough and cold products contain ingredients for pain or fever. The most common products include acetaminophen (Tylenol), ibuprofen (Motrin or Advil), and naproxen (Aleve). These are considered safe medications that won’t interact with Parkinson’s medications. Always check the ingredients or ask your pharmacist to make sure you don’t choose multiple products with the same ingredient.

With the number of OTC products available in various combinations, it makes choosing a safe and effective product overwhelming. Always ask your pharmacist what they recommend to best target your symptoms without using additional products that may be unnecessary. Most importantly, if you have Parkinson’s disease, always talk to your doctor about which products are okay and which products you shouldn’t take.

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A Running Nose in Parkinson’s: How to Catch It

By Cara Turner, Pharm.D. Candidate 2010

In a recent study it has been noted that idiopathic rhinorrhea occurs in about half of people with Parkinson’s disease.  Rhinorrhea (ry-nuh-REE-uh) refers to a runny nose, and idiopathic means that we don’t know for sure what causes it.  Normally, a runny nose is caused by allergies or a cold, and is the body’s natural defense to flush foreign substances from the sinus and nasal passages.

In people with Parkinson’s disease a runny nose is thought to be caused by the body’s decreased control over the secretion of mucous.  This results in increased nasal secretion, and thus, a runny nose.  Eating may make it worse, as well as some Parkinson’s medications, though only one drug lists increased nasal secretions as a possible side effect (Apokyn; apomorphine).

A persistent runny nose is not only embarrassing and a nuisance, but can lead to post nasal drip and coughing.  Treatment options for idiopathic rhinorrhea in people with Parkinson’s disease have not been well studied, but there are several treatments for a runny nose caused by cold and allergies that may be beneficial.  It is important to note that before you begin any treatment, you should talk to your doctor about its safety and appropriateness.

Perhaps the least expensive and most simple solution is to lightly blow the nose as needed.  While this could be useful if the rhinorrhea only occurs at certain times of the day, it may be unrealistic if it persists all day long.  Constantly blowing the nose or blowing the nose too hard can cause inflammation, which may actually make it run more.

Other possible remedies are the nasal and oral decongestants.  These medications may be likely to work for people with Parkinson’s because they decrease secretions.  However, they do have drawbacks.  Nasal sprays, such as oxymetazoline (Afrin) can only be used for 3-5 days maximum at a time or worse congestion or runny nose will occur.  Oral forms include pseudoephedrine (Sudafed) and phenylephrine (Sudafed PE), and should be avoided if you have high blood pressure, heart disease, diabetes, insomnia, or an enlarged prostate.  They also interact with the drug class MAOI’s, some of which can be used in Parkinson’s (rasagiline and selegiline).  While decongestants may be great for short term use, extended daily use could lead to serious health effects.

Acupuncture has been used to treat idiopathic rhinorrhea with varied success.  Because it is not a chemical, it could decrease medication and disease interactions, but may not be covered by insurance.  Other common treatments for a runny nose may not be effective because they work by flushing allergens out of the nose or by decreasing the body’s reaction to allergens, which doesn’t seem to be the problem in Parkinson’s.  These include sinus rinses (Neti Pot), steroid nasal sprays (Flonase), and nasal antihistamines (Astalin or Patanase).

While there is little known on idiopathic rhinorrhea in Parkinson’s disease, there are ongoing studies that are looking more in-depth into this subject.  Hopefully, with time, we may better understand the link between a runny nose, Parkinson’s disease, and possible remedies.

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How to Avoid Medication Errors: Your Five Rights

by Dr. Lindy D. Wood, Pharm.D.

Ideally, there would be no such thing as a medication error. Unfortunately, medication errors can occur and have the potential to be dangerous, particularly for an older person or someone taking multiple medications. People with Parkinson’s may be particularly vulnerable to medication errors, consider that their medication regimens are often complex, and their Parkinson’s or the medications they take for their Parkinson’s may interact with other medications.

There are numerous sources of medication errors, which can happen either in the community or in a hospital.  Some examples of errors include poor prescriber handwriting leading to the wrong medication being filled at a pharmacy, the wrong dose of a medication being given, taking two medications that interact, or even just forgetting to take medications or having medications delayed. As a patient, you have “5 Rights” when it comes to your medications: Right Patient (you!), Right Medication, Right Dose, Right Time, and Right Route (e.g. swallowed, injected, put on the skin as a patch, etc). Whether you are managing your medications at home by yourself or with a caregiver, or you are in the hospital and a nurse is giving them to you, you can take steps to make sure you achieve these rights.

The first step to avoiding a medication error is to keep an updated, accurate medication list. When you make your list, make sure to include:

  • All prescription medications AND over-the-counter medications (herbals, vitamins, supplements, medications for pain or allergies, creams, etc)
  • What dose of each medicine you take (include the strength of the tablet/capsule and how many you take)
  • How often you take each medicine
  • Why you take each medicine (this reminds not only you and your family, but also informs healthcare providers because some medications may be used for more than one reason)

If you are unsure of how to make a list or don’t know what dose of a medicine you take or why you’re taking it, ask your pharmacist or prescriber to help you make the list. Most importantly, keep the list updated every time a change in your medicine is made. Keep a copy with you at all times and also give a copy to a family member or friend so that in an emergency, healthcare workers can quickly see what medicines you take. Helpful websites for creating a medication list include:

Aside from keeping a medication list, there are other action steps you can take to help dodge medication errors. Every time you receive a new prescription from your doctor, ask the following questions:

  • What is the name of this medicine? Ask that the brand name and the generic name of the medicine are written down for you.
  • Why are you prescribing this? When can I expect a benefit with this medication?
  • How should I take this medicine?

Repeat these questions at the pharmacy, and make sure the bottle of medicine you receive matches up (name of the medicine, dose, and instructions on how to take it) with what you were told. Other questions to ask the pharmacist include:

  • Should I take this medication at a certain time of the day?
  • Should this be taken with food?
  • What side effects should I watch out for?
  • What happens if I forget to take a dose?
  • Will this interact with any of my other medications or my Parkinson’s disease?

These questions are also important to ask when you are picking out an over-the-counter medication.  In particular, some cough or cold medicines can interact with Parkinson’s medications, so it’s a good idea to ask your pharmacist for a safe recommendation.

Although we’d all prefer to stay out of the hospital, emergencies or planned procedures may warrant a visit. In addition to bringing your medication list with you to the hospital, ask your provider if you can bring in and continue taking your own medications, particularly your Parkinson’s medicines (make sure the medicines are in their original pill containers). Some hospitals will actually let you manage these medications yourself, if you’re well enough to do that.

Unfortunately, medication administration in a hospital doesn’t always coincide with the way you time your medicine at home. Make sure to tell your healthcare providers what times you take your Parkinson’s medicines and ask them what can be done to make sure you receive those on time. Occasionally a provider will write an order for you to receive your Parkinson’s medicine “as needed” (in medical language “PRN”) so that you have access to the medication when you need it and there is less delay. Explain to the nurses and doctors how important it is for you to receive your medicine on time so your body can move and function the way you need it to.

The bottom line in preventing a medication error is: Ask Questions! Don’t’ be afraid to voice your concerns or inquire about your medications.  Whether you’re at home or in the hospital, stay involved in your medication management because no one knows your body like you do!

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An Overview of Dyskinesia and the Possible Effects of Amantadine

by Michael Glockling, Pharm.D. Candidate 2010

Levodopa is one component of Sinemet® (carbidopa/levodopa), a medication commonly used by people with Parkinson’s. Carbidopa is added to levodopa to increase the amount of levodopa that reaches the brain, where it can be transformed to dopamine. Levodopa was first introduced forty years ago and is still considered to be the most effective medication available for treatment of the motor symptoms of Parkinson’s. Once converted to dopamine in the brain, levodopa eases the common motor symptoms of slowness, rigid movement, tremor, and instability.

One potential side-effect associated with long-term levodopa use is dyskinesia. Dyskinesia usually develops three to five years after starting levodopa and is associated with involuntary, erratic, dance-like movements of the arms, face, legs, and/or trunk. For s0me people the symptoms usually occur 1 to 2 hours after a dose has been absorbed and is having its peak effect. For other people, dyskinesia occurs as the levodopa starts to either take effect or wear off. Dyskinesia also tends to be more severe as the levodopa dose increases. These involuntary movements can cause discomfort and can also get in the way of normal functioning. Many people with Parkinson’s disease prefer to tolerate some involuntary movement with levodopa in exchange for the benefit of the medication, but for others, the movements are more bothersome. One available option to reduce levodopa-induced dyskinesia is amantadine.

Amantadine was first created in the 1960s as an anti-influenza medication. In 1969 it was noticed that when individuals with Parkinson’s took amantadine to help prevent the flu, they had much better control over their tremor. As a result, amantadine may be beneficial in people with Parkinson’s who have bothersome levodopa-induced dyskinesia or a prominent tremor. The motor symptoms are often alleviated immediately; however, the effect may wear off after a few months. The exact way that amantadine works is unknown, but it seems it may increase dopamine’s action in the brain.

Amantadine is available in a tablet, capsule, and liquid formulation with 100mg once daily as a common starting dose. The dose can be carefully increased as needed with help from a physician. The liquid formulation is beneficial to people who have difficulty swallowing tablets or capsules. Amantadine is cleared from the body by the kidneys, so a lower dose may be required in a person with kidney problems.

The most frequently reported side effects with amantadine are lightheadedness, nausea, confusion, insomnia, and hallucinations. Some people may also experience a very rare condition referred to as livedo reticularis. This appears as a lacy, purplish discoloration and swelling of the skin, most often the legs. This condition goes away upon discontinuation of the medication; however, there is no harm in continuing the amantadine if it is providing the desired benefit.

It is good to be aware of this possible treatment option for tremor and/or levodopa-induced dyskinesia associated with Parkinson’s disease. Amantadine can be a beneficial addition to a treatment regimen, but it is not without some potential side effects of its own.

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