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 Sinemet and Aricept 
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Joined: Sat Apr 07, 2007 1:56 pm
Posts: 54
Location: Florida
Post Sinemet and Aricept
Sinemet and Aricept are the only two meds my husband currently takes for PD symptoms and memory loss. My husband's neurologist is in the process of relocating his office so I haven't been able to speak with him about the results of the extensive testing my husband recently completed at the Memory and Wellness Center. I've posted the diagnosis here before, but in a nutshell it's mild to moderate dementia probably of the AD type plus additional Parkinson like symptoms which may be indicative of diffuse Lewy Body contribution.

Does anyone know if Sinemet can contribute to cognitive decline? If so, I'd rather see the tremor back than to see the mind go.

As for the Aricept, he takes 10mg in the morning, right after breakfast. The doctor originally prescribed it to be taken at bedtime, but since my husband has REM behavior disorder, he said the Aricept could worsen that and changed it to mornings, on a full tummy to avoid any stomach upset. My husband is very fuzzy in the mornings to early afternoon, but by mid-afternoon into evening, he becomes more alert and engaged. Any input about the best time to take Aricept would be appreciated.

Thanks so much for your help.

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Marilyn


Thu May 03, 2007 4:48 pm
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Post Re: Sinemet and Aricept
Marilyn wrote:


Does anyone know if Sinemet can contribute to cognitive decline? If so, I'd rather see the tremor back than to see the mind go.

.


Hi Marilyn,Yes Sinemet can cause agitation and anxiety and many times the dose has to be adjusted or discontinued, always go with smaller amounts, see below the side effects, I hope this helps.


Side Effects of This Medicine
Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor as soon as possible if any of the following side effects occur:

More common

Abnormal thinking: holding false beliefs that cannot be changed by fact; agitation; anxiety; clenching or grinding of teeth; clumsiness or unsteadiness; confusion; difficulty swallowing; dizziness; excessive watering of mouth; false sense of well being; feeling faint; general feeling of discomfort or illness; hallucinations (seeing, hearing, or feeling things that are not there); hand tremor, increased; nausea or vomiting; numbness; unusual and uncontrolled movements of the body, including the face, tongue, arms, hands, head, and upper body; unusual tiredness or weakness

Less common

Blurred vision; difficult urination; difficulty opening mouth; dilated (large) pupils; dizziness or lightheadedness when getting up from a lying or sitting position; double vision; fast, irregular, or pounding heartbeat; hot flashes; increased blinking or spasm of eyelids; loss of bladder control; mental depression; other mood or mental changes; skin rash; unusual weight gain or loss

Rare

Back or leg pain; bloody or black tarry stools; chills; convulsions (seizures); fever; high blood pressure; inability to move eyes; loss of appetite; pain, tenderness, or swelling of foot or leg; pale skin; prolonged, painful, inappropriate penile erection; sore throat; stomach pain; swelling of face; swelling of feet or lower legs; vomiting of blood or material that looks like coffee grounds


Thu May 03, 2007 7:28 pm

Joined: Mon Feb 05, 2007 3:43 am
Posts: 215
Location: Seattle, WA
Post 
In short, yes, Sinemet and all the dopamine agonists are known to cause more cognitive side effects while improving the movement.

Conversely, the atypical antipsychotics are believe to improve mental state but increase movement problems.

The beauty is, you get to set the knob wherever you'd like by adjust the dose of the agent; the hell is you don't have two independently adjustable knobs.

Aricept in the morning is a good idea; consider psychostimulants for the "slow start".

Eric

_________________
Cal is not the real name of a real 84 year old with DLB. I don't speak for LBDA, nor do I have clever initials behind my name, so information is provided without warranty. Caveat everybody. I blog at http://PragmaticCaregiver.blogspot.com


Fri May 04, 2007 4:20 am
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Sinemet is used to treat the movement disorder and at lower doses usually does not cause many problems. At higher doses can cause hallucinations. The dopamine agonists, COMT inhibitors and other PD meds are more likely to be difficult with increased hallucinations and psychosis.

Many dementia specialists use Aricept and other cholinesterase inhibitors in the morning to avoid the potential sleep disruption. It is important to take the medicines with a meal - oatmeal, eggs, cottage cheese, yogurt, etc to delay absorption and decrease GI side effects.

Most dementia specialists do not use stimulant medications - the side effects far outweigh anedoctal benefits.

Antipsychotic medications should be reserved for troublesome behaviors where they are quite effective and reducing the distress caused by behavior. However, if a behavior is not particularly distressing, most of us will not treat.


Fri May 04, 2007 11:52 am

Joined: Mon Feb 05, 2007 3:43 am
Posts: 215
Location: Seattle, WA
Post 
LBDdoc wrote:
Most dementia specialists do not use stimulant medications - the side effects far outweigh anedoctal benefits.


It's correct that most North American dementia specialists don't use them; on the other hand, there's twenty years of patient experience with adrafinil, the prodrug of modafinil (Provigil) in Europe, specifically in older adults, where Group Lafon markets the agent for the cognitive declines of aging.

While it seems fringe and "anecdotal" at the moment, until there's several large RCTs in the English-language journals (I had to read poorly computer-translated French to look at the adrafinil research, guided primarily by this paper from CNS Drug Reviews:

http://www.nevapress.com/cnsdr/full/5/3/193.pdf

), it's going to remain fringe and anecdotal.

In any event, itt's not just a lone voice in the woods on this; Rye at Emory published a paper on using modafinil in PD patients with dementia symptoms. Williams-Gray at Cambridge has done the same. Adler at Mayo Scottsdale reported in a small trial that modafinil was quite well-tolerated.

So I have to question the "far outweigh" language - in the trials of modafinil in people with obstructive sleep apnea, who are already considered at high risk of cardiac events, modafinil has not been shown to exacerbate existing cardiac issues. . . while I recognize that the amphetamine products are *radically* different and carry substantial risk, I am clearly missing something when it comes to the side effect profile of modafinil in this population, and welcome the opportunity to learn more.

Eric

_________________
Cal is not the real name of a real 84 year old with DLB. I don't speak for LBDA, nor do I have clever initials behind my name, so information is provided without warranty. Caveat everybody. I blog at http://PragmaticCaregiver.blogspot.com


Fri May 04, 2007 12:26 pm
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Joined: Sat Apr 07, 2007 1:56 pm
Posts: 54
Location: Florida
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Irene....thanks for the info on Sinemet. I am quite concerned about its effect on my husband's cognitive ability, although I have no way of knowing if it's the Sinemet (4 x daily) or LBD that's affecting his cognitive ability. It just seems that since the neuro upped the Sinemet to 4 x daily, his confusion has increased significantly, especially in the mornings.

Eric and LBDdoc......I have not seen my husband exhibit any behavioral problems, and certainly no psychotic behavior. The only problem has been REM sleep disturbance and even that seems to have quelled a bit as of late. He did take Provigil (200mg) this past December because I complained to his internist that he was dozing too much in the mornings even after a full night's sleep, but after about a month the doctor said to stop taking it because the improvement was insignificant and he didn't want to pile on yet another medication if it wasn't helping much. Also, the cost was HUGE, about $800+ for a 90 day supply*, and we still have about 60 pills left in the bottle. This is the first I've heard that Provigil may have a positive effect on dementia, but until a month ago I knew nothing about my husband's true disorder (other than PD or a PD-like disorder) so I didn't watch for any changes in his cognitive function. However, I will speak with his neurologist about the Provigil during our next appointment.

Thanks so much for your help.

*Isn't Provigil supposed to come off patent very shortly?

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Marilyn


Sat May 05, 2007 8:58 am
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Marilyn wrote:
so I didn't watch for any changes in his cognitive function. However, I will speak with his neurologist about the Provigil during our next appointment.


Dear Marilyn,
Ah the lessons we learn as we deal with this illness, it is like no other and we learn to watch everything. I also had to learn the way you did never really equating the meds, I have no experience with the provigil so I can't even comment on that, Eric has more knowledge in that area, this is a drug I learned after tha fact. I still think the sinemet needs to be lowered so maybe the Neuro can advice on that. Good Luck! :)


Sat May 05, 2007 9:48 am

Joined: Mon Feb 05, 2007 3:43 am
Posts: 215
Location: Seattle, WA
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Cephalon has asserted some unique patent claims for Provigil that have to do with particle size in the tablet, and those positions were not the ones that expired March 31, 2006. Litigation is ongoing.

It is insanely expensive.

Eric

_________________
Cal is not the real name of a real 84 year old with DLB. I don't speak for LBDA, nor do I have clever initials behind my name, so information is provided without warranty. Caveat everybody. I blog at http://PragmaticCaregiver.blogspot.com


Sat May 05, 2007 10:44 am
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Joined: Mon Feb 05, 2007 3:43 am
Posts: 215
Location: Seattle, WA
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Cephalon has asserted some unique patent claims for Provigil that have to do with particle size in the tablet, and those positions were not the ones that expired March 31, 2006. Litigation is ongoing.

It is insanely expensive. Insurers hate paying for it. If you don't have pharmaceutical coverage, try the warehouse stores (Sam's/Costco), as they typically have the least-expensive cash pay prices. On a drug like this, it adds up to Real Money.

Eric

_________________
Cal is not the real name of a real 84 year old with DLB. I don't speak for LBDA, nor do I have clever initials behind my name, so information is provided without warranty. Caveat everybody. I blog at http://PragmaticCaregiver.blogspot.com


Sat May 05, 2007 10:51 am
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Joined: Sat Apr 07, 2007 1:56 pm
Posts: 54
Location: Florida
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Eric.......

Yes, Provigil is indeed insanely expensive and even though we do have Medicare Part D Rx coverage, the enormous "actual" cost of this drug would throw my husband into the coverage gap very quickly. As for patent expirations on major drugs, I've often found that the generic version that follows soon after is not much cheaper. My husband takes Zoloft (now the generic Sertraline). The difference in a 90 day supply between the brand and the generic is less than $40 and the price is rising each time we refill.

Although I do understand that pharmaceutical companies bear an enormous cost in years of research and testing to develop a new drug, I still think they rip us off (i.e., why do prices of brand name drugs continue to escalate years after the drugs have been on the market?) As for the generic pharmaceutical companies who charge almost the same as the brand name drug, they're really ripping us off because they carry none of the burden and expense incurred in developing a new drug. They merely have to prove to the FDA that the composition of their product is the same as the brand name and that their manufacturing process follows FDA standards. I know that many generic drugs are quite inexpensive, but not the most widely used ones, and whether brand name or generic, every time I refill a prescription, the price goes up. In one instance, the price for one of his medications jumped over $50 in just 90 days.

I apologize for venting my anger in this forum, but I'm really ticked off and no doubt millions of other people are as well.

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Marilyn


Sat May 05, 2007 12:27 pm
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Joined: Mon Feb 05, 2007 3:43 am
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Location: Seattle, WA
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There's a whole thing of "authorized" generics as well, and six-month exclusivity. It's enough to drive a boy to drink.

It's worth doing the Part D finder every year during open enrollment - as this shakes out, the number of plans that offer coverage in the gap decreases and the out of pocket costs change - for us, we happened to luck out, that Cal's coverage actually improved for a drop in costs, and at least we have a stop loss now.

Eric

_________________
Cal is not the real name of a real 84 year old with DLB. I don't speak for LBDA, nor do I have clever initials behind my name, so information is provided without warranty. Caveat everybody. I blog at http://PragmaticCaregiver.blogspot.com


Sun May 06, 2007 11:54 pm
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Joined: Sat Apr 07, 2007 1:56 pm
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Location: Florida
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EricSEA wrote:
There's a whole thing of "authorized" generics as well, and six-month exclusivity. It's enough to drive a boy to drink.

It's worth doing the Part D finder every year during open enrollment - as this shakes out, the number of plans that offer coverage in the gap decreases and the out of pocket costs change - for us, we happened to luck out, that Cal's coverage actually improved for a drop in costs, and at least we have a stop loss now.

Eric


Eric....I did the same thing for my husband. We have the AARP plan and for 2007 they offered an "enhanced" plan that covers generics in the gap for an additional premium of $18 per month. I chose that for my husband and it's already paid for itself. He's already in the gap and his 90 day supply of generic Zoloft (Sertraline) only cost the $18 co-pay instead of the $450 retail price we would have had to pay under the regular Part D plan. Several other of his generics are also coming due for refill and I'm so happy I chose that plan for him.

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Marilyn


Mon May 07, 2007 12:49 am
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