From the Guidelines
The least acceptable option to manage wearing-off symptoms in a 70-year-old patient with Parkinson's disease taking carbidopa/levodopa 25/100 mg four times daily would be to add benztropine (Cogentin) as it is an anticholinergic agent that can exacerbate cognitive decline, constipation, and other adverse effects, particularly in elderly patients. Management of wearing-off symptoms should prioritize strategies that improve motor function while minimizing adverse effects on cognition and quality of life. Adding amantadine, rasagiline, or tolcapone (Tasmar) may be considered as these options have been shown to provide benefits in managing motor fluctuations in Parkinson's disease patients 1.
When considering the addition of new medications, it is essential to weigh the potential benefits against the risks, particularly in elderly patients who may be more susceptible to adverse effects. For example, rasagiline, a MAO-B inhibitor, has been shown to be effective in managing motor fluctuations and has a relatively favorable side effect profile 1. In contrast, benztropine, an anticholinergic agent, may worsen cognitive function and exacerbate other adverse effects, making it a less desirable option for elderly patients.
Key considerations in managing wearing-off symptoms include:
- Adjusting the timing or frequency of the current carbidopa/levodopa doses
- Adding a COMT inhibitor like entacapone
- Considering a MAO-B inhibitor such as rasagiline
- Adding an extended-release formulation of carbidopa/levodopa
- Implementing any medication changes gradually with close monitoring for side effects, particularly in elderly patients.
From the Research
Management of Wearing-Off Symptoms in Parkinson's Disease
The patient in question is experiencing wearing-off symptoms, primarily bradykinesia and rigidity, while on carbidopa/levodopa 25/100 mg 4 times a day. To manage these symptoms, several options are considered:
- Add amantadine: Amantadine can enhance dopaminergic transmission and has antiglutamate activity, making it a potential option for managing wearing-off symptoms 2.
- Add rasagiline: Rasagiline is a monoamine oxidase type B (MAO-B) inhibitor that can be used as adjunctive therapy in patients with motor fluctuations 2, 3.
- Add benztropine (Cogentin): Benztropine is an anticholinergic drug that can provide control of symptoms when used as monotherapy, but its use is limited due to psychotoxic, cognitive, and autonomic adverse events, particularly in the elderly 2, 4.
- Add tolcapone (Tasmar): Tolcapone is a catechol-O-methyltransferase (COMT) inhibitor that can reduce motor fluctuations in patients with advanced disease, but it is not mentioned in the provided studies as a direct option for the given scenario.
Least Acceptable Option
Considering the patient's age (70 years) and the potential side effects of the medications, the least acceptable option would be:
- Add benztropine (Cogentin): Due to its anticholinergic properties, benztropine can cause significant adverse effects in the elderly, such as delirium, mania, hypomania, and euthymia, as well as exacerbating cognitive and autonomic symptoms 2, 4.
Alternative Options
The other options, such as adding amantadine, rasagiline, or considering alternative treatments like dopamine agonists or COMT inhibitors, may be more suitable for managing wearing-off symptoms in this patient, depending on their individual needs and medical history 2, 3, 5.