Management and Treatment of Parkinson's Disease: A Guide for Pharmacists

Worldwide, more than 10 million people live with Parkinson's disease (PD). In the United States, approximately 60,000 people are diagnosed each year, suggesting that a total of one million people will be living with the MP by 2020.¹

pathophysiology ²

Parkinson's disease is a debilitating and incurable brain disease resulting from the deterioration and death of neurons. These neurons are specifically present in the brainstem dark substance, which are primarily responsible for the release of dopamine. Dopamine allows the transmission of smooth and coordinated movements and balances of our body. Patients only begin to experience severe motor symptoms when about 80% of their neurons have died, hence the importance of early diagnosis for effective treatment. The reason why these neurons begin to deteriorate gradually and die is unknown.

sYMPTOMS

Pharmacists should be aware of the following clinical picture of PD, which can be divided into two categories: motor symptoms and / or non-motor symptoms.

Motor symptoms include TRAP. (See the table)

Non-motor symptoms include constipation, incontinence, insomnia, depression / anxiety, muffled speech, drooling, masked facies and / or flexion on the body.

Treatment

Pharmacists are an essential resource in managing treatment options for people with PD. These professionals have the appropriate training and knowledge to provide essential information and support. Pharmacists are able to provide care to patients with PD regardless of context, community or hospital.

The following non-pharmacological and pharmacological treatment options are important and should be considered in each patient based on the symptoms and severity of the condition.

Non pharmacological^2.3

• Patients should engage in physical exercises such as high intensity training, cardiac training, swimming, etc., in order to maintain the functionality of their body.
• Patients should be made aware of the importance of maintaining proper hydration, eating high fiber meals and avoiding high fat meals to reduce constipation.
• Based on the severity of symptoms, some patients with PD could benefit from speech therapy.
• All patients may require appropriate badessment of their mental health and be referred to counseling or support groups as needed.

Pharmacological: motor symptoms⁴

The choice of treatment for people with PD depends on several factors, including the severity of the symptoms, the patients' medication preferences, the extent of the disease status and the age of the patients. The goal of therapy is to manage the severity of symptoms, delay progression of the disease, minimize complications, and improve the patient's quality of life.

The following drug clbades are approved for the management of PD symptoms:

• Carbidopa / Levodopa
• Dopamine agonists, including pramipexole, ropinirole and apomorphine
• Selective inhibitors of MAOB, including selegiline and rasagiline
• Inhibitors of COMT, such as entacapone
• Centrally acting anticholinergics, such as benztropine
• amantadine

As PD progresses, patients' medications will need to be adjusted as they will begin to experience more side effects as these medications run out of steam more quickly. Pharmacists can provide badistance to reduce side effects, treat difficult dosing regimens, and ensure effective communication between provider and patient.

The role of a pharmacist⁵

Here are some of the many steps that pharmacists can take to ensure patient safety and optimal results:

• Monitor the safety and effectiveness of drugs.
• Review the patient's current drug profile to make sure they do not exacerbate / worsen the symptoms of PD with medications such as prochlorperazine, haloperidol, risperidone, paliperidone, and / or metoclopramide.
• Report to the patient's PCP any potentially intolerable side effects.
• Monitor drug interactions such as: carbidopa / levodopawith non-selective MAO inhibitors because these clbades are contraindicated and require a 2 week separation period.
• Offer alternatives to patients who can no longer swallow oral medications.
• Advise patients not to crush oral medications before checking with their PCP or pharmacists.
• Educate patients and their families on the importance of adherence and not abruptly discontinue any treatment.

Conclusion

Parkinson's disease is a chronic movement disorder that will progressively worsen overtime. PD can not be cured, but different treatments can help relieve and manage symptoms drastically. By adhering to appropriate treatment, patients with Parkinson's disease can lead a long and manageable life. Pharmacists play a vital role in PD and can improve the quality of life for these patients through proper communication, counseling and supervision.

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Engy F. Kheir, PharmD, RPh is a community pharmacist in Orlando, Florida.

Shekher Mohan, PhD is Professor of Pharmaceutical Sciences at the University of Manchester, College of Pharmacy, Natural Sciences and Health in Fort Wayne, Indiana.

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References

1. Parkinson Foundation. Understanding Parkinson's Disease: Statistics. Parkinson Foundation website. http://parkinson.org/Understanding-Parkinsons/Causes-and-Statistics/Statistics. Accessed August 20, 2019.
2. Patel T, Guidelines for Pharmacists Chang F. Parkinson. CPJ / CPP 2014; 147 (3): 161-170. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4025881/pdf/10.1177_1715163514529740.pdf. Accessed August 20, 2019.
3. Fleisher J. Tarsy D. Nonpharmacological Management of Parkinson's Disease. Up to date. Updated September 19, 2018. Accessed August 21, 2019.
4. Parkinson's Disease in Adults: Diagnosis and Treatment – Complete Guidelines. NICE NICE NICE Directive. https://www.ncbi.nlm.nih.gov/books/NBK447153/pdf/Bookshelf_NBK447153.pdf. Updated in 2017. Accessed August 20, 2019.
5. Several entries. Lexi-Drugs. Lexi-Comp online. Lexi-Comp, Inc. Hudson, OH. http://online.lexi.com/crlonline. Accessed August 21, 2019.