Pharmacy & Therapeutics - October 2008 - (Page 590)

COVER STORY Medical Management of Parkinson’s Disease Mar vin M. Goldenberg, PhD, RPh, MS of idiopathic PD suggests that environmental factors such as rural living, drinking well water, and heavy metal and hydroParkinsonism is a clinical syndrome characterized by at carbon exposure have small but demonstrable contributions least two of four cardinal features: bradykinesia (slowness and to the risk of idiopathic PD. Interestingly, cigarette smoking, minimal movement), rigidity, resting tremor (trembling), and caffeine consumption, and nonsteroidal anti-inflammatory an impairment of postural balance leading to disturbance of gait drug use are associated with protection against the illand falling.1 The most common type of parkinsonism ness.8 is idiopathic Parkinson’s disease (PD), first described by James Parkinson, an English physician, in 1817 as The cumulative exposures to supposed toxins, facparalysis agitans (the shaking palsy). Dr. Parkinson tors associated with aging of the CNS, or other yet undescribed the major symptoms of the disease that characterized cell death mechanisms may be responwould later bear his name. For the next century and sible for the onset of PD in later life and for its a half, scientists pursued the causes and treatment of progression. Genetic factors may play a role, particuthe disease, defining its range of symptoms, its distrilarly if the disease begins before age 50. Nine genetic Mar vin M. bution among the population, and its prospects for linkages and four genes have so far been identified in Goldenberg, cure. PD.9 The pathological hallmark of PD is a loss of the pig- PhD, RPh, MS Society pays an enormous price for PD. According mented, dopaminergic neurons of the substantia nigra pars to the National Parkinson Foundation, each patient spends an compacta in the brain, with the appearance of intracellular average of $2,500 a year for medications.5 After factoring in inclusions known as Lewy bodies.2,3 In the early 1960s, reoffice visits, Social Security payments, nursing-home expenditures, and lost income, the total cost to the nation is estimated searchers identified a fundamental defect that is a hallmark of to exceed $6 billion annually.10 the disease: the loss of brain cells that produce an important chemical, dopamine, which helps direct muscle activity. ProPD affects approximately 50,000 Americans each year and gressive loss of dopamine-containing neurons is a feature of more than 500,000 at any one time. Obtaining an accurate normal aging; however, most people do not lose the 70% to 80% count of the number of cases may be impossible, however, of the dopaminergic neurons required to cause symptomatic because many people with early-stage disease assume that PD.4 Without treatment, PD progresses over 5 to 10 years to their symptoms are the result of normal aging and they do not seek help from a physician. Diagnosis is also difficult because a rigid, akinetic state in which patients are incapable of caring symptoms of other conditions resemble those of PD. Doctors for themselves. Death may result from complications of immomay initially tell patients that they have another disorder; conbility, such as aspiration pneumonia and pulmonary embolism. versely, patients with a similar disease may be initially told that Pharmacological attempts to restore dopaminergic activity they have PD. with levodopa and dopamine agonists have been successful in PD strikes men somewhat more often than women.7 PD alleviating many of the clinical features of PD. An alternative but complementary approach has been to restore the normal knows no social, economic, or geographic boundaries. Some balance of cholinergic and dopaminergic influences on the studies show that PD is less common in African-Americans and basal ganglia with anticholinergic drugs. The availability of Asians than in Caucasians.11 Scientists have not been able to effective pharmacological treatment has radically altered the explain this apparent lower incidence in certain populations, prognosis of PD; in most cases, good functional mobility can but it is reasonable to assume that all people face a similar risk. be maintained for many years, and the life expectancy of adeETIOLOGY quately treated patients is increased substantially. Parkinson’s disease occurs when certain nerve cells in the EPIDEMIOLOGY substantia nigra (i.e., “black substance”) region of the brain die or become impaired and degenerate.12 Normally, these neuPD is a progressive disorder of the central nervous system (CNS), and it affects 1 to 1.5 million people in the U.S.5,6 The rons produce dopamine, a chemical messenger responsible for transmitting signals between the substantia nigra in the basal annual incidence of idiopathic PD increases from about 20 ganglia and the next “relay station” of the brain, the corpus per 100,000 persons in the fifth decade of life to about 90 per striatum, to generate smooth, purposeful muscle activity. Loss 100,000 persons in the seventh decade of life. The approximate of dopamine causes the nerve cells of the striatum to fire out age of onset is 60 years.7 Extensive epidemiological research of control, leaving patients unable to direct or control their movements in a normal manner. In patients with PD, 60% to 80% The author is President of Pharmaceutical and Scientific Services or more of dopamine-producing cells in the substantia nigra at Marvin M. Goldenberg, LLC, in Westfield, New Jersey. His e-mail may be lost. The cause of this cell death or impairment is not address is marvinmgoldenberg@verizon.net. clear.13 Accepted for publication May 14, 2008. Although the pathogenesis of PD is unknown, one mecha- INTRODUCTION 590 P&T® • October 2008 • Vol. 33 No. 10

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Pharmacy & Therapeutics - October 2008 Contents Editorial Medication Errors Prescription: Washington New Drugs/Drug News/ New Medical Devices Drug Forecast Medical Management of Parkinson’s Disease Why Is Health Care Regulation So Complex? The Next President’s Prescription for Action on Drugs Trends in Managing Multiple Sclerosis Product Profiler: Sancuso®

Pharmacy & Therapeutics - October 2008

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