Parkinson’s disease is believed to be related to an imbalance of dopamine and acetylcholine and a deficiency of dopamine in certain areas of the brain, so drug therapies are aimed at increasing levels of dopamine and/or antagonizing the effects of acetylcholine. Drug therapy does not cure the disease but is used to slow the progression of symptoms. Common medications used to treat Parkinson’s disease are carbidopa/levodopa, selegiline, and amantadine.^[1]

Carbidopa/Levodopa

Carbidopa/levodopa is the most common drug used to treat Parkinson’s disease and is usually started as soon as the client becomes functionally impaired.

Mechanism of Action

Administration of dopamine is ineffective in the treatment of Parkinson’s disease because it does not cross the blood-brain barrier, but levodopa, the metabolic precursor of dopamine, does cross the blood-brain barrier and presumably is converted to dopamine in the brain. Carbidopa is combined with levodopa to help stop the breakdown of levodopa before it is able to cross the blood-brain barrier. Additionally, the incidence of levodopa-induced nausea and vomiting is less when it is combined with carbidopa.

Indications for Use

Carbidopa/levodopa is indicated for Parkinson’s disease. It is also used to treat restless leg syndrome.

Nursing Considerations Across the Lifespan

Carbidopa/Levodopa is recommended for use in clients older than age 18.  It can take several weeks to see positive effects and this should be explained to clients and their caregivers.

The drug is contraindicated for use with MAOIs. All clients should be observed carefully for the development of depression with concomitant suicidal tendencies.

Clients taking carbidopa and levodopa have reported suddenly falling asleep without prior warning of sleepiness while engaged in activities of daily living (including operation of motor vehicles). Clients should be advised to exercise caution while driving or operating machines during treatment with carbidopa and levodopa.

Sporadic cases of symptoms resembling neuroleptic malignant syndrome (NMS) have been reported in association with dose reductions or withdrawal of certain antiparkinsonian agents. Therefore, clients should be observed carefully when the dosage of levodopa is reduced abruptly or discontinued.

Periodic evaluations of hepatic, hematopoietic, cardiovascular, and renal functions are recommended during extended therapy. The most common adverse effect of carbidopa/levodopa is dyskinesia, which may require dosage reduction.

Clients should be instructed to plan their meal times around medication times to improve their ability to use their utensils and to avoid diets high in protein due to decreased absorption of the medication.

Adverse/Side Effects

Hallucinations and psychotic-like behavior have been reported with dopaminergic medications. Clients taking dopaminergic medications may experience intense gambling urges, increased sexual urges, intense urges to spend money or indulge in binge eating, and/or other intense urges, and the inability to control these urges. These urges stop when the dosage is decreased or the medication is discontinued.

A higher risk for melanoma has been reported. Occasionally, dark red, brown, or black color may appear in saliva, urine, or sweat after ingestion of carbidopa and levodopa. Although the color appears to be clinically insignificant, garments may become discolored.^[2],^[3],^[4]

Client Teaching & Education

Clients should take their medications at regular intervals as directed.  If gastric irritation is experienced, clients may eat food shortly after taking medications but high-protein foods may impair drug action. Medications may cause increased drowsiness, dizziness, and orthostatic changes. Clients should carefully assess their skin to monitor for new lesions and any abnormality should be reported to the healthcare provider.

Carbidopa/levodopa Medication Card

Now let’s take a closer look at the medication card for carbidopa-levodopa.^[5] Medication cards like this are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information related to each class of medication is outlined below.  Prototype or generic medication examples are also hyperlinked to a free resource at Daily Med. On the home page, enter the drug name in the search bar to read more about the medication.

Selegiline

Selegiline is often used in conjunction with carbidopa-levodopa when clients demonstrate a deteriorating response to this treatment. It is helpful to control symptom fluctuations.^[6]

Mechanism of Action

Selegiline inhibits MAO-B, blocking the breakdown of dopamine.^[7]

Indications for Use

Selegiline capsules are indicated as an adjunct in the management of Parkinsonian clients being treated with levodopa/carbidopa who exhibit deterioration in the quality of their response to this therapy. There is no evidence from controlled studies that selegiline has any beneficial effect in the absence of concurrent levodopa therapy.

Nursing Considerations Across the Lifespan

Large doses of selegiline may inhibit MAO-A that promotes the metabolism of tyramine in the GI tract, which can cause a hypertensive crisis.

Adverse/Side Effects

Side effects are dose-dependent, with larger doses posing a hypertensive crisis risk in conjunction with the consumption of food or beverages with tyramine. Higher doses can increase the risk for hypertensive crises.

Client Teaching & Education

Clients should be advised to avoid foods high in tyramine. Additionally, medications may cause increased drowsiness, dizziness, and orthostatic changes. If clients experience abnormal behaviors such as hallucination, sexual urges, gambling, etc., this should be reported promptly to the healthcare provider.

Selegiline Medication Card

Now let’s take a closer look at the medication card for selegiline.^[8]

Amantadine

Amantadine is used in the early stages of Parkinson’s disease but can be effective in moderate or advanced stages in reducing tremor and muscle rigidity.^[9]

Mechanism of Action

The exact mechanism of action is unknown. Amantadine is an antiviral drug that acts on dopamine receptors.^[10]

Indications for Use

Amantadine is used for Parkinson’s disease, medication-induced extrapyramidal symptoms, and influenza A.

Nursing Considerations Across the Lifespan

Use cautiously with renal impairment. This drug may cause suicidal ideation and should not be stopped abruptly or can cause Parkinsonian crisis. Neuroleptic Malignant Syndrome (NMS) has been reported in association with dose reduction or withdrawal of amantadine therapy.

Adverse/Side Effects

Suicide ideation, congestive heart failure, and peripheral edema can occur. This drug can cause intense gambling urges, increased sexual urges, intense urges to spend money uncontrollably, and other intense urges with an inability to control them. There is an increased risk of melanoma.

Adverse reactions reported most frequently are nausea, dizziness (lightheadedness), and insomnia. This drug can also cause anticholinergic side effects, impaired thinking, and orthostatic hypotension.^[11]

Client Teaching & Education

Clients should take medications as directed and ensure they do not skip or double doses. Medications may cause drowsiness, dizziness, and orthostatic blood pressure changes. Clients should avoid using this medication with OTC cold medications or alcoholic beverages. If clients, family, or caregivers note worsening depression or suicidality, this should be reported immediately to the healthcare provider.

Amantadine Medication Card

Now let’s take a closer look at the medication card for amantadine.^[12] Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication.