What causes Parkinson's disease exacerbation?

From the Guidelines

Parkinson's disease exacerbation should be addressed promptly by adjusting medication regimens, identifying potential triggers, and ensuring proper nutritional management to prevent malnutrition and related complications, as evidenced by the ESPEN guideline on clinical nutrition in neurology 1. To manage exacerbations, increasing the dosage of levodopa/carbidopa (Sinemet) by 25/100 mg per dose or adding an extra dose during the day may help, as well as adding or increasing dopamine agonists like ropinirole (0.25-1 mg three times daily) or pramipexole (0.125-0.5 mg three times daily) 1. Some key points to consider in managing Parkinson's disease exacerbation include:

• Identifying and managing potential triggers such as infections, dehydration, constipation, sleep disturbances, stress, and certain medications (particularly antipsychotics, antiemetics like metoclopramide, and some antidepressants) 1
• Maintaining consistent medication timing, staying hydrated, exercising regularly, and managing constipation with fiber supplements and stool softeners 1
• Ensuring proper nutritional management, including regular monitoring of body weight and nutritional assessment at least on a yearly basis, to prevent malnutrition and related complications 1
• Considering supplementation with vitamin D, as low vitamin D levels have been associated with the risk of developing Parkinson's disease and slowing disease progression 1
• Monitoring homocysteine levels and considering supplementation with vitamin B12 and folate, as levodopa use can cause hyperhomocysteinemia 1 During exacerbations, physical therapy focusing on gait training and balance exercises can help manage motor symptoms, and medical evaluation is necessary if symptoms don't improve within 1-2 weeks of medication adjustment, or if there's sudden severe worsening 1.

From the FDA Drug Label

In double-blind, placebo-controlled trials in advanced Parkinson’s disease, dyskinesia was much more common in patients treated with ropinirole than in those treated with placebo Among those patients receiving both ropinirole and L-dopa in advanced Parkinson’s disease trials, 34% were reported to experience dyskinesia, compared with 13% of patients treated with placebo Ropinirole may cause or exacerbate pre-existing dyskinesia in patients treated with L-dopa for Parkinson’s disease.

Ropinirole may exacerbate Parkinson’s disease symptoms, particularly dyskinesia, in patients treated with L-dopa. Decreasing the dose of dopaminergic medications, such as ropinirole, may ameliorate this adverse reaction 2.

From the Research

Parkinson's Exacerbation

• Parkinson's disease is a progressive neurodegenerative disorder that can be exacerbated by various factors, including the progression of the disease itself 3.
• The main therapeutic strategies for Parkinson's disease treatment rely on dopamine precursors, inhibition of dopamine metabolism, and dopamine receptor agonists 4.
• Levodopa combined with carbidopa is still the most effective treatment for symptoms of Parkinson's disease, and dopamine agonists can be used alone or as an adjunct to levodopa 5.
• Addition of a peripherally-acting COMT inhibitor or an MAO-B inhibitor to levodopa can reduce motor fluctuations in patients with advanced disease 5.
• Rasagiline, a novel MAO-B inhibitor, has been shown to provide statistically significant improvement when added to dopamine agonist therapy and is well tolerated 6.

Treatment Options

• Dopamine-based therapies typically help initial motor symptoms, while nonmotor symptoms require nondopaminergic approaches 3.
• Rehabilitative therapy and exercise complement pharmacologic treatments, and individuals experiencing complications may benefit from advanced treatments such as deep brain stimulation 3.
• The initiation of pharmacological therapy in Parkinson's disease should be based on the individual patient's needs, and current evidence supports the use of levodopa as initial symptomatic treatment in most patients 7.
• Monoamine oxidase-B inhibitors and dopamine agonists can be reserved as potential adjunct treatments later in the disease course 7.

Disease Management

• Parkinson's disease is a heterogeneous disease with rapidly and slowly progressive forms, and treatment involves pharmacologic and nonpharmacologic approaches 3.
• Palliative care is part of Parkinson's disease management, and future research will need to establish effective disease-modifying treatments 3.
• The development of motor complications arising from the early initiation of levodopa has been largely mitigated by the outcomes of recent studies, and early initiation of dopaminergic therapies can reduce disability 7.