January 22, 2010

New Complexity in Parkinson Disease

The following guest column appears in print in today's Sarasota Herald-Tribune's Opinion pages. The author, Dr. Dean Sutherland, is the Medical Director for The Neuro Challenge Foundation, a nonprofit organization dedicated to providing medical, educational and emotional support to those suffering with debilitating life challenges such as Parkinson Disease. Dr. Sutherland is a keynote speaker at tomorrow's Annual Parkinson Symposium at the SMH Institute for Advanced Medicine.

The Jan. 19 edition of Health and Fitness in the Herald-Tribune carried a New York Times piece by Denise Grady outlining drug withdrawal reactions that can occur when patients stop or reduce the dosage of dopamine agonists (pramipexole and ropinerole), a class of drugs used by Parkinson disease sufferers. As medical director of Neuro Challenge Foundation, I have received several inquiries from interested and concerned patients who read this article. There are a large number of Parkinson patients in the Sarasota/Manatee area, roughly 5,000 to 8,000 individuals, and many of them could be affected by this issue.

The small study from New York Presbyterian/Cornell-Weill Medical Center found that, of 26 patients who tapered off on or discontinued these drugs, five had withdrawal symptoms similar to cocaine withdrawal. Two of the five had no lasting effects, but the other three had to go back on the drugs to alleviate anxiety, panic attacks, depression, sweating, nausea, pain, fatigue, dizziness or drug cravings. The patients taken off these dopamine agonists in the study were already having side effects, such as impulse control (harmful obsessions or compulsions), drops in blood pressure or hallucinations. We see this in the hospital setting when patients cannot take their Parkinson medications. My colleagues and I are often called for neurological advice when these patients undergo intestinal surgery or require a breathing tube in the intensive care unit.

Many years ago, Parkinson disease was considered a relatively simple disease resulting from loss of dopamine producing cells in one part of the brain, the substantia nigra. Clinical symptoms involved tremor, slowness, balance problems and shuffling gait. Fixing the problem meant providing the missing dopamine in the form of a pill called Sinemet, which we still use today. To find more effective treatments, molecules that act like dopamine were created: hence, dopamine agonists. While we have many more drugs to treat Parkinson, dopamine and dopamine agonists remain the most powerful and, not surprisingly, have the most powerful side effects.

We now know that Parkinson disease is actually quite complicated, involving many different neurotransmitters, not just dopamine. Most, if not all, of the brain becomes involved eventually. Interestingly, evidence has been mounting for several years now that Parkinson is a multi-organ disease, with pathological changes that can clearly be seen in the gastrointestinal tract and the heart. Clinical symptoms (in addition to the above) may include loss of sense of smell, constipation, low blood pressure, depression or anxiety. A fascinating recent development is the theory outlined by Nobel Prize winner Dr. Stanley Prusiner, along with Dr. Warren Olanow, that Parkinson disease may be an infectious process relying on abnormal proteins rather than viruses, bacteria or fungi.

Until recently, there was a notable gap between local delivery of care to Parkinson patients and the programs offered by national organizations. However, as is happily the case with other issues, things are different in Sarasota. I have the pleasure of working with dozens of individuals willing to step forward and fill this gap. Sarasota is home base for a number of groundbreaking programs in the field of Parkinson disease that patients and caregivers should take advantage of, including free resource and referral programs, support groups, Web-based information, fitness classes and alternative movement-oriented activities specifically designed for Parkinson patients, like tai chi, yoga, chair yoga, pool therapy, acupuncture, boxing, and ballroom dancing. Backed up by recent studies, Parkinson disease specialists now promote exercise as a major piece in the treatment puzzle.

Being at your best, whether you have Parkinson disease or another health problem, requires information and dedication. Ask questions of your doctor, read as much as you can, attend lectures and support groups, exercise regularly, and carefully follow your doctor's plan of care for you.

About Dean Sutherland: Dean Sutherland, M.D., Ph.D, is a neurologist specializing in the treatment of Parkinson disease and founder of the Southeastern Center for Parkinson Disease in Sarasota.

About the Parkinson Symposium:
The 12th Annual Parkinson Symposium, sponsored by Sarasota Memorial Hospital and the Neuro Challenge Foundation, will be held Saturday at the SMH Institute for Advanced Medicine, 5880 Rand Blvd. off Clark Road. Registration begins at 8:30 a.m., with the program from 10 to noon. It is the largest patient-centered Parkinson disease symposium in Florida. International experts provide cutting-edge scientific information and clinically relevant facts that patients can use to enhance their lives. The suggested donation is $20 per person. On the Web: www.neurochallenge.org. Phone: 926-6413