deterioration). Unwanted involuntary movements (dyskinesias) may appear, and there may be sudden switches from being 'on' and able to move to being 'off' and immobile. These longer-term effects can sometimes be improved by altering the type or amount of Sinemet or Madopar, or the frequency with which the drug is taken. If this is not satisfactory, other types of drug can be combined with levodopa.

Dopamine agonists

Dopamine agonists directly stimulate the parts of the brain where dopamine works. Their effects often last longer than levodopa and may suit some people better than Sinemet or Madopar. Dopamine agonists may be taken alone, but are commonly used in conjunction with Sinemet or Madopar to 'smooth out' control of symptoms in people whose response to treatment is beginning to fluctuate. A more recent approach has been to start treatment with a dopamine agonist alone, before using levodopa, because of the advantages of dopamine agonists (listed below). They produce fewer long-term side effects such as 'on/off' fluctuations and dyskinesias. Rotigotine (Neupro) is a transdermal patch which is applied daily. The skin patch provides much the same benefits and side effects as the oral dopamine agonists. Oral dopamineagonists are best taken with meals.

Advantages

Control of symptoms during the day may last longer than is usually the case with Sinemet or Madopar and where this applies, people with Parkinson's may be less prone to long-term side effects such as the 'on/off' effect and dyskinesias.

Disadvantages

Dopamine agonists require careful introduction, with the dose gradually increased until a satisfactory response is achieved. At the lowest doses, people may experience a lack of effect or, paradoxically, a temporary worsening of their Parkinson's, but usually benefits appear as the dosage is increased. Dopamine agonists are usually introduced very gradually and slowly increased. This is to minimise the risk of symptomatic postural hypotension and/or sustained low blood pressure. When used alone, dopamine agonists are generally considered to be less effective than the standard forms of levodopa (Sinemet or Madopar). Some people with Parkinson's are unable to continue taking dopamine agonists because of side effects, which can include:
If you have any form of heart or lung disease, or symptoms that might be related to a problem with the heart or lungs, be sure to inform your medical team if you are taking one of the dopamine agonist drugs.

Dopamine agonists - subcutaneous

Apomorphine is a dopamine agonist that is administered by under the skin (subcutaneous) injection. When sudden fluctuations in symptoms, in spite of all efforts to adjust medication, occur, injections of apomorphine may be used - almost like a 'rescue remedy' - between doses of their usual tablets. Many people self-inject intermittently, with a syringe or a ready-loaded disposable APO-go pen. In some cases a more continuous supply of apomorphine is required which is administered via a pump. This portable, battery-driven syringe pump works by the insertion of a needle under the skin. It can be injected into the outside thigh, or into the stomach (below the navel).

Advantages

It acts very quickly and reliably so that people who need to be active at specific times can continue with their normal activities. It can bring great relief to people who are experiencing extreme variations in mobility and prolonged 'off' periods.

Disadvantages

Apomorphine can only help those people with Parkinson's who show a response to Sinemet or Madopar. It can cause nausea and therefore another drug called domperidone (Motilium), which acts specifically against nausea and sickness, has to be taken in addition, at least while apomorphine is being introduced.
(published with permission in writing from:http://www.parkinsons.org.uk)




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