Worldwide, there are more than 10 million people living with Parkinson Disease (PD). In the United States, there are about 60,000 individuals diagnosed yearly, foreshadowing a total of 1 million patients that will be living with PD by the year 2020.1 

Pathophysiology 2

Parkinson Disease is an incurable, debilitating brain disorder that results from the deterioration and death of neurons. These neurons are specifically present in the substantia nigra within the brain stem which are primarily responsible for the release of dopamine. Dopamine allows for the transmission of smooth, coordinated movement and balance of our bodies. Patients do not start to experience severe motor symptoms until about 80% of their neurons have died, making early diagnosis important for effective treatment. The reason why these neurons start to progressively deteriorate and die remains unknown.

Symptoms

Pharmacists should be aware of the following clinical presentation of PD which can be divided in two categories: motor symptoms and/or nonmotor symptoms. 

Motor symptoms include TRAP. (see table)



Nonmotor symptoms include constipation, incontinence, insomnia, depression/anxiety, muffled speech, drooling, masked facies, and/or bent over body. 

Treatment
Pharmacists are an essential resource in management of treatment options for individuals with PD. These professionals are equipped with the proper training and knowledge to provide vital information and support. Pharmacists are able to provide care for PD patients regardless of their setting, community or hospital.

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

Nonpharmacological2,3
  • Patients should engage in physical exercise such as high-intensity training, cardiac training, swimming, etc., in order to maintain functionality of their body.
  • Patients should be educated on the importance of maintaining adequate hydration, eating meals that contain high fiber, and avoiding high-fat meals in order to reduce constipation.
  • Based on the severity of symptoms, some PD patients may benefit from speech therapy.
  • All patients may need proper evaluation for mental health and referred to counseling or support groups as needed. 
                                                                                                                                                              
Pharmacological: Motor Symptoms4

Choice of therapy for individuals with PD depend on several factors that include severity of symptoms, patients’ preferences on medications, extent of disease state, and patients’ ages. The goal of therapy is to manage the severity of symptoms, delay disease progression, minimize complications, and improve the patient’s quality of life.

The following classes of medications are approved for symptom management of PD:
  • Carbidopa/levodopa
  • Dopamine agonists, including pramipexole, ropinirole, and apomorphine
  • Selective MAOB inhibitors, including selegiline, and rasagiline
  • COMT inhibitors, such as entacapone
  • Centrallyacting anticholinergics, such as benztropine
  • Amantadine
As PD progresses, patients’ medications will need adjustment as they will start to experience more adverse effects from these medications wearing off more quickly. Pharmacists can provide assistance with minimizing adverse effects, addressing difficult medication schedules, and ensuring effective communication between the provider and the patient.

The Role of a Pharmacist5 

Below are some of the many steps that pharmacists can take to ensure patient safety and optimal outcomes:
  • Monitor for safety and efficacy of medications.
  • Review the patient’s profile for current medications to ensure that they do not exacerbate/worsen PD symptoms with drugs such as prochlorperazine, haloperidol, risperidone, paliperidone, and/or metoclopramide.
  • Report any adverse effects to patient’s PCP that may be intolerable.
  • Monitor for drug-drug interactions such as: carbidopa/levodopa with nonselective MAO inhibitors as these classes together are contraindicated and require a 2-week separation period.
  • Offer alternatives to patients that can no longer swallow oral medications.
  • Advise patients not to crush any oral medications before checking with their PCP or pharmacists.
  • Educate patients and their families on the importance of adherence and not to abruptly discontinue any medications.

Conclusion

Parkinson Disease is a chronic movement disorder that will progressively worsen overtime. There is no cure for PD but different therapies can help alleviate and manage symptoms drastically. With adherence to the proper treatment, PD patients can live a long, manageable life. Pharmacists play an integral role in PD and can improve these patients’ quality of life with proper communication, counseling and monitoring.
 
Engy F. Kheir, PharmD, RPh is a community pharmacist in Orlando, Florida.

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



References
  1. Parkinson's Foundation. Understanding Parkinson's: Statistics. Parkinson's Foundation website. http://parkinson.org/Understanding-Parkinsons/Causes-and-Statistics/Statistics. Accessed August 20, 2019.
  2. Patel T, Chang F. Parkinson’s Disease Guidelines for Pharmacists. CPJ/RPC 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. Nonpharmacologic Management of Parkinson Disease. UpToDate. Updated September 19, 2018. Accessed August 21, 2019.
  4. Parkinson’s disease in Adults: Diagnosis and Management – Full Guideline. NICE Guideline NG71. https://www.ncbi.nlm.nih.gov/books/NBK447153/pdf/Bookshelf_NBK447153.pdf. Updated 2017. Accessed August 20, 2019.
  5. Multiple Entries. Lexi-Drugs. Lexi-Comp Online. Lexi-Comp, Inc. Hudson, OH. http://online.lexi.com/crlonline. Accessed August 21, 2019.