A Critical Reappraisal of the Worst Drugs in Parkinson’s Disease

You can find out more about NPF's National Medical Director, Dr. Michael S. Okun, by also visiting the NPF Center of Excellence, University of Florida Center for Movement Disorders & Neurorestoration.

What are the worst drugs for Parkinson’s disease patients?  Couldn’t a simple list be assembled and disseminated to the Parkinson’s community?  Recently Ed Steinmetz, an experienced neurologist in Ft. Meyers, FL pointed out to me, a list approach published in the Public Citizen Newsletter (www.worstpills.org).  The approach was to list every drug associated with a single confirmed or unconfirmed symptom of Parkinson’s disease or parkinsonism.  Parkinson’s disease is defined as a neurodegenerative syndrome (common symptoms include tremor, stiffness, slowness, posture and gait issues), whereas parkinsonism encompasses a wider net of drug induced and other potential causes. In parkinsonism, symptoms are similar to Parkinson’s disease, but patients do not have Parkinson’s disease.  Patients and family members confronted with a simple “drug list” approach may falsely conclude that most medicines are bad for Parkinson’s disease, and that any medicine may cause parkinsonism.  This concept is in general, incorrect. 

Although the approach is well-meaning, it is in need of a major revision, as Parkinson’s disease and parkinsonism are too complex to summarize by simple lists. In this month’s column, I will try to summarize the key information that patients and family members need to know about the “worst pills,” for Parkinson’s disease and parkinsonism.

It is well known that drugs that block dopamine worsen Parkinson’s disease and also worsen parkinsonism, whereas dopamine replacement therapy (Carbidopa/Levodopa, Sinemet) may improve symptoms.  One of the big issues facing many Parkinson’s disease patients is psychosis (hallucinations, illusions, and behavioral changes such as paranoia).  How does one administer dopamine replacement therapy, which may in some cases induce psychosis, and at the same time administer dopamine blocker drugs aimed at alleviating psychosis?  Will the drugs cancel each other out?  There are two dopamine blockers that will not cancel out dopamine replacement, and therefore will not appreciably worsen Parkinson’s disease.  One is Quetiapine (Seroquel), and the other is Clozapine (Clozaril).  Clozapine is the more powerful of the two drugs, but it requires weekly blood monitoring.  Other classical dopamine blocking drugs, also referred to as neuroleptics (e.g. Haldol), worsen Parkinson’s disease and parkinsonism.

Patients may not be aware that some common drugs used for conditions such as headache or gastrointestinal dysmotility may also block dopamine, and concomitantly worsen Parkinson’s disease, or alternatively result in parkinsonism.  These drugs include Prochlorperazine (Compazine), Promethazine (Phenergan), and Metoclopramide (Reglan).  They should be avoided.  Also, drugs that deplete dopamine such as reserpine and tetrabenazine may worsen Parkinson’s disease and parkinsonism and should be avoided in most cases.  Substitute drugs that do not result in worsening of parkinsonism can be utilized, and these include Ondansetron (Zofran) for nausea, and erythromycin for gastrointestinal motility.

Antidepressants, anxiolytics, mood stabilizers, thyroid replacement drugs, and antihypertensives are in general safe, and do not worsen Parkinson’s disease and parkinsonism.  They appear commonly on lists such as that provided by the Public Citizen, but these lists are misleading.  There may be rare reactions that lead to worsening of Parkinson’s disease or parkinsonism with these drugs, but these are very rare occurrences.   The bigger issue is drug-drug interactions.  The most commonly encountered in Parkinson’s disease is mixing a MAO-B Inhibitor (Selegline, Rasagiline, Azilect, Zelapar, Selegiline Hydrochloride Dissolvable) with a pain medicine such as Meperidine (Demerol).  Also, MAO-A Inhibitors (e.g. Pirlindole) should not be taken with antidepressants.  And finally it should be kept in mind that in rare instances mixing an antidepressant with another class of drugs can in select cases result in a serotonin syndrome.  Finally, remember, there are very common “other” side effects of antidepressants, anxiolytic drugs, mood stabilizers, thyroid replacement drugs, and antihypertensives.

In summary, the list approach to the worst pills in Parkinson’s disease and parkinsonism needs a critical reappraisal.  A more refined approach would take into consideration the complexities of Parkinson’s disease and parkinsonism, and would appreciate that with physician guidance, and with few exceptions, most drugs can be safely and effectively administered in Parkinson’s disease and parkinsonism.

Posted: 1/3/2011 12:23:54 PM by Cathy Whitlock


Browse current and archived What's Hot in PD? articles, the National Parkinson Foundation's monthly blog for people with Parkinson's written by our National Medical Director, Dr. Michael S. Okun. 

August 2014
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July 2014
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June 2014
Is light therapy a potential treatment modality in Parkinson’s disease?

May 2014
How does the most common genetic cause of Parkinson’s Disease (LRRK2) cause Parkinson’s disease and could it be used to help develop a better therapy?

April 2014
An Update on DAT Scanning for Parkinson’s Disease Diagnosis

March 2014
Could Northera (Droxidopa) Be an Alternative Treatment for Low Blood Pressure and Passing Out Symptoms?

February 2014
The Dream of a Pill Free Existence and the Continuous Dopaminergic Pump for the Treatment of Parkinson's Disease

January 2014
Should I take Inosine to Raise my Uric Acid Levels and Treat my Parkinson’s Disease?

December 2013
Could Fungus and Mold be an Important Contributor to Parkinson’s Disease?

November 2013
Pimavanserin and the Hope for a Better Drug for Hallucinations and Psychosis in Parkinson’s Disease

October 2013
Halting of the Creatine Study

September 2013
The Importance of Identifying and Treating Caregiver Strain

August 2013
Putting Parkinson’s Disease Information into the Palm of Your Hand: Parkinson’s Enters the Smartphon

July 2013
What Parkinson’s Disease Patients Need to Know about H. Pylori Gastrointestinal Infections

June 2013
A2A Receptor Antagonists and Parkinson’s Disease Treatment

May 2013
Another Setback for Trophic Factor Treatment in Parkinson's Disease

April 2013
IPX066 and What Patients Really Want in New Carbidopa/Levodopa (Sinemet) Formulations

March 2013
The Weather Forecast for Parkinson’s Disease Calls for Worldwide Economic Storm

February 2013
Defeating the Barriers to Implementing Exercise Regimens in Parkinson’s Disease Patients

January 2013
When should you start medication therapy for Parkinson’s disease?

December 2012
Neurologist Care Reduces Hospitalizations in Parkinson's Disease

November 2012
A Victory in Court for Parkinson's Disease Patients who Require Ongoing Rehabilitative Therapies

October 2012
Given the recent FDA announcement about Mirapex (pramipexole), should I be worried about dopamine agonists?

September 2012
What about the new Parkinson’s Disease Vaccine? What should I know?

August 2012
Caffeine as a Potential Treatment for Parkinson’s Disease

July 2012
Time to Consider GPi DBS for Parkinson’s Disease: A Shift in the Practice of Patient Selection for DBS

June 2012
A New Treatment for Parkinson’s Disease-Related Constipation

May 2012
Too Many Pills: Improving Delivery Systems for Parkinson’s Disease Drugs

April 2012
Measuring Quality and Assessing Depression in Parkinson's Disease

March 2012
Watch out for Unexpected Obstacles if You Use a Cueing Strategy to Break Freezing of Gait in Parkinson’s Disease

February 2012
Pill Color, Generic Medications and Insurance Issues: Important Medication-Related Tips for the Parkinson’s Disease Patient

January 2012
Are Blood Tests for Parkinson’s Disease on the Horizon?

December 2011
Placing Stem Cells in Animal Models of Parkinson’s Disease: Another Important Step

November 2011
Important News for the Parkinson’s Disease Community: More Evidence that Sinemet and Madopar are Not Toxic and do Not Accelerate Disease Progression

October 2011
The Case for All Parkinson’s Disease Patients to be Co-managed by a Primary Care-Neurologist Team

September 2011
Scientists say Research on Brain Proteins Involved in Parkinson’s Disease is “Shaping” Up

August 2011
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July 2011
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June 2011
How Will Group Visits for Parkinson’s Disease Fit into the Future of Parkinson’s Disease Care?

May 2011
Why Patients Should be Wary of Chelation Therapy for Parkinson’s Disease

April 2011
Opening the Door to Gene Therapy in Parkinson’s Disease: The Need for Refinement of the Technology and Approach

March 2011
Does it Matter if I Can’t Get Brand Sinemet?

February 2011
Should I get a DaTscan or PET scan to confirm my diagnosis of Parkinson’s disease?

January 2011
A Critical Reappraisal of the Worst Drugs in Parkinson’s Disease

December 2010
Environmental Risks for PD: Manganese, Welding, Mining, and Parkinsonism

November 2010
Calling for the FDA to Revise the Eight Sinemet a Day Rule

October 2010
Dry Cleaning Solvents and Potential Environmental Risks for Developing Parkinson’s Disease

September 2010
Maintaining the Balance: Why Parkinson’s Disease Patients Need to Understand Drug Recalls, Withdrawals, and Safety Alerts

August 2010
Shining a Light on Parkinson’s Disease: Optogenetics Has a Bright Future in Research

July 2010
Poor Medication Management of Parkinson's Disease During Hospital Admissions: Patients and Families Can Improve Their Hospital-Based Management

June 2010
Why Are Patches and Continuous Release Technology a Big Deal to Parkinson's?

May 2010
Is the PD SURG Trial Another Surge Forward for DBS Therapy?

April 2010
Cycling in PD in Those Who Can’t Walk: Is it Possible?

March 2010
New iPS Stem Cells for PD: What Does it Mean?

February 2010
Time for Comprehensive Care Networks for PD

January 2010
Is Parkinson's Disease a Prion Disease?

December 2009
Parkinson's Disease Linked to Gaucher's Disease

November 2009
Brain Cells Keep Time Stamps: Implications for Parkinson's Disease Therapies

October 2009
Is it Safe to Have an MRI with a DBS in Place?

September 2009
Take Care of Your Bones as They Are Affected in Parkinson's Disease (Even in Men)

August 2009
Is it Time to Start Paying Attention to Pain Symptoms in Parkinson's Disease Patients?

July 2009
Glutathione Fails to Demonstrate Significant Improvement in PD Symptoms

June 2009
Keeping an Eye on Trials Important to the Parkinson's Disease Patient

May 2009
Increased Risk of Melanoma in Parkinson's Disease

April 2009
Finally a DBS Expert Consensus Statement Aimed at Their True Customers: The Patients

March 2009
Pesticides and Environmental Exposure in Parkinson's disease: Should We Stay Away From the Stink Truck?

February 2009
Is Exercise Effective Treatment and Protection Against PD?

January 2009
Why are Transplant Trials Struggling to Succeed in the Treatment of PD?

December 2008
Are Monoamine Oxidase Inhibitors Disease Modifying or Neuroprotective in PD?

November 2008
Update on Gene Therapy for Parkinson's Disease

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Each month, we will feature a new column by NPF's National Medical Director, Dr. Michael Okun, on the latest developments in Parkinson's disease research. Read the latest "What's Hot in PD?" below.

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