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geri:parkinsons [June 2019]
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 ==== Levodopa ==== ==== Levodopa ====
 <callout type="​success">​{{fa>​arrow-circle-right?​color=green}} See main article: **[[meds:​dopamine-agonists:​carbidopa-levodopa|]]**</​callout>​ <callout type="​success">​{{fa>​arrow-circle-right?​color=green}} See main article: **[[meds:​dopamine-agonists:​carbidopa-levodopa|]]**</​callout>​
-Administration of dopamine alone is ineffective because ​dopamine cannot cross the blood–brain barrier. Thus, the main treatment for all patients with Parkinson'​s is levodopa, a dopamine precursor. When ingested alone, levodopa is rapidly converted to dopamine outside the CNS. Thus carbidopa, a DOPA decarboxylase inhibitor (DDCI), is added to inhibit the conversion of levodopa to dopamine outside the CNS.+The main treatment for PD is levodopa, a dopamine precursor (since ​dopamine ​itself ​cannot cross the blood–brain barrier). When taken orally, levodopa is rapidly converted to dopamine outside the CNS. Thus carbidopa, a DOPA decarboxylase inhibitor (DDCI), is added to inhibit the conversion of levodopa to dopamine outside the CNS. 
 + 
 +==== On-Off Phenomenon ==== 
 +The on-off phenomenon is a consequence of sustained levodopa treatment in patients with Parkinson'​s disease. It is characterized by a switch between mobility and immobility, which occurs as an end-of-dose or “wearing off” worsening of motor function or, much less commonly, as sudden and unpredictable motor fluctuations.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC1033307/​|Lees,​ A. J. (1989). The on-off phenomenon. Journal of Neurology, Neurosurgery & Psychiatry, 52(Suppl), 29-37.]])]
  
 ==== Dopamine Agonists ==== ==== Dopamine Agonists ====
-Dopamine agonists ​such as [[meds:​dopamine-agonists:​ropinirole|ropinirole]] and [[meds:​dopamine-agonists:​pramipexole|pramipexole]] ​are also used.+Dopamine agonists ​include the ergot derivatives: ​[[meds:​dopamine-agonists:​bromocriptine|bromocriptine]], cabergoline,​ dihydroergocryptine,​ lisuride, ​and pergolide. There are also the non-ergot derivatives:​ apomorphine,​ piribedil, ​[[meds:​dopamine-agonists:​pramipexole|pramipexole]], [[meds:​dopamine-agonists:​ropinirole|ropinirole]],​ rotigotine.
  
 ==== Dopamine Agonist Withdrawal Syndrome (DAWS) ==== ==== Dopamine Agonist Withdrawal Syndrome (DAWS) ====
 Dopamine agonist withdrawal syndrome (DAWS) is a complication that affects up to 19% of PD patients who undergo a dopamine agonist taper. It was initially described in 2010 as a severe stereotypical cluster of psychiatric and physical symptoms occurring with dopamine agonist withdrawal.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​28104232|Yu,​ X. X., & Fernandez, H. H. (2017). Dopamine agonist withdrawal syndrome: A comprehensive review. Journal of the neurological sciences, 374, 53-55.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​23686524|Nirenberg,​ M. J. (2013). Dopamine agonist withdrawal syndrome: implications for patient care. Drugs & aging, 30(8), 587-592.]])] ​ The symptoms of DAWS include anxiety, panic attacks, dysphoria, depression, agitation, irritability,​ suicidal ideation, fatigue, orthostatic hypotension,​ nausea, vomiting, diaphoresis,​ generalized pain, and drug cravings. Dopamine agonist withdrawal syndrome (DAWS) is a complication that affects up to 19% of PD patients who undergo a dopamine agonist taper. It was initially described in 2010 as a severe stereotypical cluster of psychiatric and physical symptoms occurring with dopamine agonist withdrawal.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​28104232|Yu,​ X. X., & Fernandez, H. H. (2017). Dopamine agonist withdrawal syndrome: A comprehensive review. Journal of the neurological sciences, 374, 53-55.]])][([[https://​www.ncbi.nlm.nih.gov/​pubmed/​23686524|Nirenberg,​ M. J. (2013). Dopamine agonist withdrawal syndrome: implications for patient care. Drugs & aging, 30(8), 587-592.]])] ​ The symptoms of DAWS include anxiety, panic attacks, dysphoria, depression, agitation, irritability,​ suicidal ideation, fatigue, orthostatic hypotension,​ nausea, vomiting, diaphoresis,​ generalized pain, and drug cravings.
- 
-==== On-Off Phenomenon ==== 
-The on-off phenomenon is a consequence of sustained levodopa treatment in patients with Parkinson'​s disease. It is characterized by a switch between mobility and immobility, which occurs as an end-of-dose or “wearing off” worsening of motor function or, much less commonly, as sudden and unpredictable motor fluctuations.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC1033307/​|Lees,​ A. J. (1989). The on-off phenomenon. Journal of Neurology, Neurosurgery & Psychiatry, 52(Suppl), 29-37.]])] 
  
 ===== Resources ===== ===== Resources =====
 == For Providers == == For Providers ==
   * [[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2658001/​|Poewe,​ W., et al. "​Diagnosis and management of Parkinson’s disease dementia."​ International journal of clinical practice 62.10 (2008): 1581-1587.]]   * [[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2658001/​|Poewe,​ W., et al. "​Diagnosis and management of Parkinson’s disease dementia."​ International journal of clinical practice 62.10 (2008): 1581-1587.]]