From the Guidelines
For tremor-dominant Parkinson's disease with intolerance to NeuroPro, rasagiline, Azilect, and Sinemet, the most effective alternative treatment option is to use transdermal rivastigmine, as suggested by the American Academy of Sleep Medicine 1. This recommendation is based on the latest clinical practice guideline for the management of REM sleep behavior disorder, which is often associated with Parkinson's disease. Although the primary focus of the guideline is on REM sleep behavior disorder, the suggestion to use transdermal rivastigmine for secondary RBD due to medical conditions like Parkinson's disease implies its potential benefits in managing symptoms related to the disease, including tremors.
Some key points to consider when using transdermal rivastigmine for tremor-dominant Parkinson's disease include:
- Starting with a low dose and gradually increasing as needed and tolerated
- Monitoring for potential side effects such as nausea, vomiting, and dizziness
- Regular follow-up appointments to assess efficacy and adjust treatment plans accordingly
Other treatment options, such as anticholinergics (e.g., trihexyphenidyl, benztropine), amantadine, and beta-blockers (e.g., propranolol), may also be considered, but their effectiveness and tolerability can vary among individuals. Additionally, alternative dopamine agonists like pramipexole or ropinirole might be explored, given their different mechanisms or delivery methods, which could potentially avoid the specific side effects experienced with previous medications. However, transdermal rivastigmine is the most recently recommended option by a reputable clinical guideline 1, making it a preferable choice for patients with tremor-dominant Parkinson's disease who have intolerance to other medications.
From the Research
Treatment Options for Tremor Dominant Parkinson's Disease
Given the intolerance to NeuroPro 4 mg/24 hours, rasagiline, Azilect, and Sinemet, the following treatment options can be considered:
- Levodopa combined with carbidopa is still the most effective treatment for symptoms of Parkinson's disease, as stated in 2.
- Dopamine agonists can be used alone before the introduction of levodopa or as an adjunct to levodopa, according to 2.
- Addition of a peripherally-acting COMT inhibitor or an MAO-B inhibitor to levodopa can reduce motor fluctuations in patients with advanced disease, as mentioned in 2.
Alternative Treatments
- Amantadine may have mild symptomatic benefit and can decrease levodopa-induced dyskinesias, as stated in 2.
- Anticholinergics are rarely used because of their adverse effects, but can be a useful addition to levodopa for control of tremor and drooling, according to 2.
- Subcutaneous apomorphine should be available for rescue use in patients with 'off' episodes, as mentioned in 2.
- Deep brain stimulation is an option for patients with levodopa-induced motor complications and relatively intact cognition, as stated in 2.
Rasagiline as a Treatment Option
- Rasagiline (Azilect) is a useful option in the symptomatic treatment of adult patients with Parkinson's disease, as stated in 3.
- Rasagiline monotherapy significantly improved tremor symptoms in early PD, independent of disease duration, compared with placebo, according to 4.
- The addition of rasagiline adjunct therapy significantly improved tremor symptoms in levodopa-treated patients with motor fluctuations, as mentioned in 4.
- Rasagiline is generally well tolerated as monotherapy and adjunctive therapy, as stated in 3, 5, 6.