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Pharmacotherapy for Parkinson Disease

Farmakoterapi Penyakit Parkinson 

Class/Drug Usual Daily Dosage Clinical Use and Side Effects
Dopaminergic Agents 
Precursor amino acid: levodopa Dyskinesia, dystonia, hallucinations, hyperkinesia, dizziness, fatigue, abdominal pain, constipation, diarrhea, nausea, vomiting, cardiac abnormalities, orthostatic hypotension, discolored urine
  Carbidopa-levodopa (Sinemet) 200–2000 mg/day, divided three times daily Increase by 1 tablet every day or every other day to a maximum of 8 tab/day
  Controlled release (Sinemet CR) 200–1400 mg/day, divided twice daily Increase by 1 tablet every 3 days to a maximum of 8 tab/day
  Madopar CR 100/25mg (L-dopa and benserazide) 1–8 tabs 4–6 times daily Introduce gradually
  Carbidopa-levodopa-entacapone (Stalevo) 12.5 mg carbidopa with 50 mg levodopa and 200 mg entacapone twice daily Used when other medications become less effective
Increase slowly to a maximum of 8 tab/day
Dopamine agonists Somnolence, sudden onset of sleep (caution with driving), confusion, hallucinations, hypotension
  Bromocriptine 2.5–60 mg/day Adjust every 2 weeks
    1.25 mg twice daily
  Pramipexole 0.125 mg three times daily Adjust every week up to a maximum of 1.5 mg three times daily
  Ropinirole 0.25 mg three times daily Adjust every week up to a maximum of 12–16 mg
Monamine oxidase B inhibitors Sleep disturbance, light-headedness, nausea, abdominal pain, confusion, hallucinations
  Selegiline (deprenyl) 5 mg at breakfast and lunch No dosage titration required
Indirect agonists Hallucinations, dry mouth, livedo reticularis, ankle swelling, myoclonic encephalopathy in setting of renal failure
  Amantadine 100–300 mg/day Avoid in patients with cognitive impairment
Catecholamine-O-Methyltransferase (COMT) inhibitors  Effective only with levodopa and given in combination to reduce levodopa-induced dyskinesias; enables levodopa dosage to be reduced, increase levodopa bioavailability, and prolongs its half-life; reduces "off" time and increases "on" time
  Tolcapone 300–600 mg/day, or 100 or 200 mg three times daily Worsening of levodopa-induced dyskinesias (as evidenced by improvement with decrease in levodopa dosage), diarrhea, nausea, vivid dreams, visual hallucinations, sleep disturbances, daytime drowsiness, headache, hepatotoxicity
  Entacapone1 200 mg, twice to eight times daily, with each dose of carbidopa-levodopa
Other Drug Classes 
Anticholinergics2 Confusion, sleepiness, blurred vision, constipation
  Trihexyphenidyl 2–15 mg/day
  Biperiden 1–8 mg/day Avoid in patients with cognitive impairment or patients older than 65.
Novel neuroleptics Used for psychosis and unusual tremor
  Clozapine 12.5–100 mg/day Fatal neutropenia, somnolence
  Quetiapine 12.5–100 mg/day Somnolence, potential aggravated parkinsonism
  Amitriptyline 10–50 mg/day at bedtime Sleep fragmentation, dry mouth, forgetfulness, blurred vision, constipation
  Baclofen 10–80 mg/day Dystonic cramps, sleepiness, dizziness

Tab, tablet; CR, controlled release.

1No hepatotoxicity reported.
2May worsen motor symptoms on discontinuation; tapering is needed.

Current Diagnosis & Treatment Family Medicine 2nd Edition (McGraw-Hill) 2007

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