No Harm in Using Levodopa Early, so Please Don’t Prescribe a Dopamine Agonist

For those who are either new to, or unfamiliar with Parkinson’s Disease, one of the things that seems to surprise most people is that the prescription drugs have no effect one the disease itself. The drugs provide only symptomatic control. Whether you take the drugs or not, the disease progresses (gets worse), and the drugs have less ability to control the symptoms…requiring larger or more frequent doses…and/or becoming less effective.

At a certain level, this seems highly suspicious. You need more and more of a drug…are we sure the drugs are not making it worse?

Then, there’s another issue. The most effective drug for controlling PD symptoms is carbidopa levodopa, but it has side effects. After 5 years of taking the drug, 40-50% of patients will develop dyskinesias, with the majority of patients developing dyskinesias after 10 years of treatment. Dyskinesias are the uncontrollable body sways that are stereotypical of PD patients.

There is a school of thought among some neurologists (and a larger proportion of their patients) that you should delay taking levodopa medication until it is absolutely necessary, especially for those diagnosed with PD at a younger age.

One argument for this approach is to save those good years of symptom control with levodopa for later in life. The problem is there is no proof that if you wait, you’ll get those good years…with or without meds, the underlying PD keeps getting worse, and will make it more difficult for levodopa to effect symptoms.

The other argument is the fear that levodopa may actually cause PD to progress more rapidly.

A recent study says there is no reason for this second concern, and that their results show “No Harm in Using Levodopa Early in Parkinson’s for Symptom Relief...levodopa, in combination with carbidopa, did not have a disease-modifying effect on Parkinson’s disease, either beneficial or detrimental, over the 80 weeks of the trial.” That’s good news, because as an alternative to levodopa, many of these neurologists prescribe dopamine agonists (DA), a category of drugs that have a surprising efficacy in destroying lives.

The problem is that the side effects of dopamine agonists (Mirapex/pramipexole, Reqip/ropinirole) can be more troublesome…increased impulsive and compulsive behaviors…hypersexuality, porn addiction, risky activities, gambling addiction. There are many heartbreaking stories of how these dopamine agonist drugs have ruined lives. By contrast, dyskinesia seems far less worrisome.

The American Academy of Neurology recently published a study titled “Longitudinal analysis of impulse control disorders in Parkinson disease” which looked at 411 people who at the start of the study had been diagnosed with Parkinson’s Disease for 5 years or less, and were then clinically followed for at least 5 years. They found that 46% of those who were prescribed dopamine agonists developed impulse control disorders. 46% … and those were the ones who would admit it…how many of the other 54% were not able to admit it, or recognize the signs? It bears repeating, this is a category of drugs that have a surprising efficacy in destroying lives.

Fortunately, discontinuing the DA does seem to resolve these issues. However, discontinuing the DA is not as easy as it sounds. For some, quitting a dopamine agonist is like quitting a hard drug. If you’re taking a DA, you’ve probably been warned not to abruptly stop taking it, because of something called DAWS, or dopamine agonist withdrawal syndrome. It is very important to talk to your doctor if you wish to discontinue taking a DA.

If you want to delay taking levodopa, that’s your choice. But don’t be fooled into thinking a dopamine agonist is a safe alternative.

Sources:

Levodopa-induced-dyskinesias clinical features, incidence, risk factors, management and impact on quality of life.
https://www.ncbi.nlm.nih.gov/pubmed/23938226

No Harm in Using Levodopa Early in Parkinson’s for Symptom Relief, but the Drug Does Not Provide a Disease-Modifying Effect, Study Finds
https://journals.lww.com/neurotodayonline/Fulltext/2019/03070/No_Harm_in_Using_Levodopa_Early_in_Parkinson_s_for.6.aspx

Longitudinal analysis of impulse control disorders in Parkinson disease
https://n.neurology.org/content/91/3/e189