Treatment Options for Parkinson's Disease
Medication is the primary treatment for symptoms of Parkinson's disease (PD). In a few cases, surgery may also be an option. It is very important for you, your family and/or caregivers to develop a solid understanding of the treatment options that may be available. Focusing on exercise, stress management, proper nutrition and other available complimentary therapies is also part of living well with PD. Do I need a Neurologist?
According to the Canadian Guidelines on Parkinson's Disease, people suspected of having Parkinson's should be referred to a neurologist for diagnosis and ongoing care. A neurologist is a physician who diagnoses and treats disorders of the nervous system. A medical referral by a family physician or a medical specialist is required for a consultation. The neurologist wil report findings to the family physician. Neurologists are located throughout BC, although people living in small towns and rural communities may have to travel some distance for a consultation. Many community neurologists treat a variety of neurological disorders including Parkinson's but they may not specialize in one specific disorder. To look for a family doctor or a neurologist in your area, please go to website of the College of Physicians and Surgeons of BC and click or call them at 1-800-461-3008. Neurologists at Pacific Parkinson's Research Centre (PPRC), located at the University of British Columbia, specialize in Parkinson's disease and other movement disorders. You can be treated at PPRC with a referral from either a family doctor or a neurologist. Similarly, the Jim Pattison Outpatient Care and Surgery Centre, located in Surrey, has neurologist who specialize in PD and other movement disorders. Keep in mind that there may be a significant wait list so get your referral in sooner rather than later. Patients of PPRC are eligible for participation in clinical trials and they have access to support from the clinic nurses, social worker and physiotherapist. You do not need to participate in research in order to be a patient at the Centre. Information about clinical trials can be obtained by visiting their Cont'd…
Parkinson Society British Columbia
600 – 890 West Pender Street. Vancouver, BC V6C 1J9 604 662 3240 1 800 668 3330 Last Updated: May 6, 2016

What medications are used to treat Parkinson's?
Below are some of the most commonly used types of medication: • Levodopa (l-dopa, Sinemet): converts into dopamine in the brain.
Agonists: mimic the action of dopamine in the brain by stimulating receptors within the
brain and include medications such as Mirapex (pramipexole), Requip (ropinirole) and bromocriptine (Parlodel), and Neupro Patch (rotigotine). • Anticholinergic agents: correct an imbalance between dopamine and acetylcholine in the
brain and include medications such as Artane (Trihexyphenidyl), Cogentin (Benztropine), Apo-trihex, benztropine (Cogentin) and trihexyphenidyl (Artane). • COMT inhibitors: block an enzyme that breaks down levodopa. A common one is Comtan
Stalevo (Levodopa/carbidopa/entacapone): substitutes individual y administered
immediate-release levodopa/carbidopa + entacapone. Used to replace immediate-release levodopa/carbidopa (without entacapone) when patients experience end-of-dose wearing • Monoamine-Oxidase-B-Inhibitors (MAO-B): block an enzyme that breaks down levodopa
and include medications such as Azilect (rasagiline). • Amantadine (symmetrel): Enhances dopamine release by blocking glutamate, a neuro-
When someone has only mild symptoms which do not interfere with their quality of life, they may decide, together with their physician, to postpone drug treatment until symptoms worsen. During that time, they may decide to rely on a healthy lifestyle by focusing on exercise, stress management and diet. Medications can, however, provide relief or a significant decrease in symptoms. Increasing the amount of dopamine can al eviate the symptoms but does not slow the progression of Parkinson's. As the symptoms worsen, more medication may be needed. Taking medication on time is a crucial part of treatment.
It is very important for the person with Parkinson's and their family and friends to understand the actions and side effects of medications and what improvement can be reasonably expected. As Parkinson's is a very individual condition, medication is prescribed and adapted to individual needs and can help to achieve good symptom control. Response to medication varies from person to person and not every medication wil be considered suitable for everyone. Cont'd…
Parkinson Society British Columbia
600 – 890 West Pender Street. Vancouver, BC V6C 1J9 604 662 3240 1 800 668 3330 Last Updated: May 6, 2016

Ask your physician and/or pharmacist for information about medications and possible side effects. If side effects are experienced, they should be reported to the physician as soon as possible. Timing is Everything!
If you are taking medications to treat Parkinson's, timing of your doses of medication is extremely
important. If you are recently diagnosed, you may not notice any difference in your mobility or your
symptoms when you forget to take a dose. As the disease progresses, however, timing your medication becomes critical. This is primarily due to the nature of the medication and how your Why is timing so important? • Medications must be taken on time to maximize normal functioning and symptom control. Delaying your medication can decrease its effectiveness and interrupt your symptom control. A delay may also increase anxiety. • A regular schedule may help delay the development of motor fluctuations down the • When a medication routine is interrupted, it may take hours or days to return to optimal Some people with Parkinson's experience heightened anxiety when they are "off", that is, when their medications are not working. For maximum physical and emotional comfort, take your pil s on For more information, have a look at our Medication on Time resources on our website – Are generic medications as effective as brand-name medications?
As brand-name drugs get older, they cease to be protected by the patent held by the pharmaceutical company that developed the drug. Once this happens, the drug can be 'copied' and produced more cost-effectively. This copied medication is cal ed the generic version. The generic medications are, in most cases, identical to the brand-name drug and most people using them are satisfied with them. In some instances, however, people using the generic medication find that it is not as effective as the brand-name drug. One example is Sinemet, where some people with Parkinson's have found this to be the case. Many drug insurance plans wil only pay for the generic version of a medication and the purchase of the brand-name drug can become a financial burden to the patient. If you find that the generic version is not as effective, talk to your doctor about obtaining "Special Authorization" from BC
Pharmacare for coverage of the brand-name product. Cont'd…
Parkinson Society British Columbia
600 – 890 West Pender Street. Vancouver, BC V6C 1J9 604 662 3240 1 800 668 3330 Last Updated: May 6, 2016

Your doctor can complete a Special Authorization form and submit it to Pharmacare on your behalf, describing the need for the brand-name medication. Patients of Pacific Parkinson's Research Centre (PPRC) can have these forms fil ed out by the Centre staff. Others can download the forms from the BC Ministry of Health Services website - You may also wish to review the Parkinson Society British Columbia Advocacy Handbook to learn about our activities relating to health care and medication availability in BC - Do the medications have side effects? If so, how are they handled?
Al pharmacological agents (medication, vitamins, and supplements) can cause side effects. Drugs used to treat Parkinson's are no exception but this does not mean they should be avoided. Side effects for al of the common medications for Parkinson's may be reversed by lowering the dosage or discontinuing treatment. In addition, there are simple measures to control most of them. The more common side effects include: If you are feeling nauseated in spite of taking medications after food, speak to your doctor or your Parkinson's nurse. Your doctor may be able to prescribe a medication for you to control the nausea. In some cases the nausea medication may only be needed for the first weeks or months of treatment, after which time the Parkinson's medication may be tolerated more effectively by your system. Sefor more tips. Dizziness
This is often caused by low blood pressure (hypotension). Dizziness most often occurs in the early stages of treatment and during periods of hot weather, but it often responds to simple measures and may wear off over time. However, if your balance is poor and you feel dizzy, you may fal and this can lead to a fracture with serious consequences. See for more information. Impulsive or Compulsive Behaviour
Drug therapy may contribute to behaviour changes in people with Parkinson's disease. Examples include risk-taking, excessive gambling, cleaning, shopping or obsessive interest in sex. When this behaviour is excessive it can damage relationships and cause great financial and personal hardship. It is vital for changes in behaviour to be reported to the family physician or specialist even though this may be embarrassing.
Parkinson Society British Columbia
600 – 890 West Pender Street. Vancouver, BC V6C 1J9 604 662 3240 1 800 668 3330 Last Updated: May 6, 2016

A few people find that their anti-Parkinson's drugs make them suddenly very sleepy. If you sleep wel at night but stil have excessive daytime sleepiness you should talk to your physician who may recommend adjusting your medication, or adding another medication commonly used to al eviate some of the daytime sleepiness. Dyskinesia
Dyskinesia refers to the uncontrolled movements, often of the upper body, that are a common side effect of high dosages of levodopa. If you are concerned about dyskinesia, talk to your doctor about possibly reducing the dosage of levodopa. Are there medications I should not take while taking Parkinson's medications?
Yes, there are medications that are strictly contraindicated (must not be taken) with Parkinson's medications, including: • All Neuroleptics (a class of drugs used mainly in the treatment psychiatric conditions),
except "atypicals" (a limited number of medications with properties unlike the standard • All conventional antipsychotic medications, such as "Haloperidol", "Respiridone", and
"Olanzapine" • Major tranquilizers (a class of drugs used to treat symptoms such as severe agitation
Certain drugs for nausea including "prochlorperazine" (Compazine) and
"metoclopramide" (Reglan and Maxeran) • Demerol (must be used with caution)
Never assume that a medical professional is aware that you take Parkinson's medication and, further, is aware of the contraindications. You must inform al of your doctors about these critical restrictions. This is particularly important in an emergency situation, surgery or hospitalization when you may be seen by a physician who is unfamiliar with your situation. Contact PSBC to obtain a "I have PD Card", which contains information about these restricted drugs, and carry it with you at all times. What about surgery for Parkinson's?
Deep Brain Stimulation (DBS) is a form of surgical therapy for the treatment of Parkinson's disease and essential tremor. It involves placing a metal wire into a specific site in the brain and stimulation of the site with electrical impulses. DBS has shown to be beneficial for certain select patients by helping the motor symptoms as wel as some of the non-motor symptoms of Parkinson's. Surgery is NOT a standard treatment for Cont'd…
Parkinson Society British Columbia
600 – 890 West Pender Street. Vancouver, BC V6C 1J9 604 662 3240 1 800 668 3330 Last Updated: May 6, 2016

everyone with Parkinson's and is not an alternative to drug therapy. It is considered only when al medical options have been exhausted. In a limited number of cases, surgery can be effective. The best candidates for surgery meet criteria addressing the length of time since diagnosis, the kind of symptoms, reaction to medications, overal physical health, and overal mental health and stability. For more information, request a copy of our Deep Brain Stimulation help sheet. What else can help in the management of symptoms?
Exercise can maintain flexibility of joints, muscle strength, improve circulation to the heart and lungs and aid digestion. It also has a positive psychological effect, helping to deal with day-to-day stress and giving the person a sense of control over the condition. It does not alter the fact that a person has Parkinson's but it can help how they feel about it. Exercise in combination with good drug therapy can help a person to remain active and enhance the quality of life. Stretching exercise, aerobic exercise and strengthening exercises are important. Many people with Parkinson's find that yoga, Tai Chi or Qui Gong (gentle form of Tai Chi) are helpful along with walking and swimming. Safety, joint protection and balance are important considerations when exercising. Start slowly and
consult your physician before starting a new activity.
Physiotherapy is a treatment that uses physical means to relieve pain, regain range of movement, restore muscle strength and return patients to the normal activities of daily living. People with Parkinson's can benefit from an assessment by a physiotherapist as a way of identifying and treating specific areas of the body where weakness or stiffness is a concern. Physical therapists can recommend exercises to address specific concerns. If you are a patient at Pacific Parkinson's Research Centre, you can also make an appointment with their physical therapist who can assess you and refer you to a community therapist. Massage Therapy
Massage therapy has shown to provide temporary relief from pain and stiffness in addition to enhancing relaxation and stress management. Parkinson Society British Columbia is very fortunate to be associated with the West Coast College of Massage Therapy in New Westminster, BC. A special clinic for people with Parkinson's and their caregivers is held on Thursday evenings. Cont'd…
Parkinson Society British Columbia
600 – 890 West Pender Street. Vancouver, BC V6C 1J9 604 662 3240 1 800 668 3330 Last Updated: May 6, 2016

To find a physical therapist, go to theand click on "Find a Physio" or contact us 1-800-668-3330 to help you find one in your local area.
To make an appointment please phone:
604.520.1830 (be sure to indicate you are booking for the Parkinson's Clinic).
The clinic is located at:
613 Columbia Street (near 6th Street) New Westminster, BC.
Nutrition can help to maintain your best level of health if you have Parkinson's. If you have nutrition-related questions or develop problems such as weight change, poor appetite, difficulty chewing or swal owing, or constipation, consultation with a registered dietician may be helpful. There is no special diet for people with Parkinson's. Eat a variety of foods each day from the four food groups as indicated by theto obtain al nutrients needed for good health. Some people with Parkinson's may notice that their medications do not work as wel when they take them with protein. In these cases, people may wish to take their medication either an hour before, or an hour after, meals with protein. It is not recommended that people with Parkinson's remove protein from their diet - rather, they may need to have it at different times in the day. Speech Therapy
Many people with Parkinson's develop speech difficulties. Changes in speech may occur as a result of decreased coordination or reduced movements of the muscles involved in breathing, voice, pronunciation, and prosody (rhythm, intonation, and speaking rate). Often the first change noted in speech is loss of volume resulting in a soft or fading voice. The first indication may be frequent requests by family and friends to repeat what has been said. A Speech-Language Pathologist can evaluate speech problems, provide information and recommend a program. A particular form of speech therapy that is helpful for people with Parkinson's is cal ed Lee Silverman Voice Therapy (LSVT). You may wish to contact the B.C. Association of Speech/Language Pathologists & Audiologists for general information about speech therapy or to locate one trained in LSVT, visit Cont'd…
Parkinson Society British Columbia
600 – 890 West Pender Street. Vancouver, BC V6C 1J9 604 662 3240 1 800 668 3330 Last Updated: May 6, 2016

Are there alternative treatments that can be beneficial?
After the diagnosis of Parkinson's, sometimes people search for different methods of treating the symptoms. Presently, there is considerable interest in alternative treatments. When investigating alternative treatments, consider the following: • What is the evidence of the effectiveness? The best evidence appears in peer-reviewed
scientific journals. Treatments which have not been put through the rigors of scientific evaluation should be approached with caution. • What is the cost of the treatment? The cost of some treatments is exorbitant and it is
not uncommon for a person, desperate for relief, to pour considerable savings into a treatment that is speculative at best. • Can the treatment do harm? The risks associated with any treatment must be clearly
explained and completely understood. Of particular concern, is whether or not any supplement or other pil s dangerously interact with Parkinson's medication. • What is the source of supplement and how is the potency regulated?
Use extreme caution when undertaking an alternative treatment. Inform your physician before embarking on any alternative treatment. Parkinson Society British Columbia
600 – 890 West Pender Street. Vancouver, BC V6C 1J9 604 662 3240 1 800 668 3330 Last Updated: May 6, 2016


REQUEST FOR QUOTATION GAIL WEBSITE VENDOR, Vendor Code : 101019938 RFQ Due on : 22.08.2006 at 14:00 Hrs ISTTender Opening Date : 22.08.2006 at 15.00 Hrs IST Dear Sir(s)/Madam, GAIL (India) Ltd. invites you to submit your offer in sealed envelope, superscribing RFQ No. & Due datefor the following item(s) in complete accordance with enquiry documents/attachments:


Journal of Steroid Biochemistry & Molecular Biology xxx (2005) xxx–xxx The xenoestrogen bisphenol A in the Hershberger assay: androgen receptor regulation and morphometrical reactions indicate no major effects Tsuyuki Nishino , Thilo Wedel , Oliver Schmitt , Katja B¨uhlmeyer , Martin Sch¨onfelder , Christian Hirtreiter , Thorsten Schulz , W. K¨uhnel , H. Michna