Prescription Medicine

Comtan^® is a prescription medicine for the treatment of symptoms of Parkinson’s Disease in people already taking a medicine called levodopa. The tablet contains 200mg of entacapone. Check with your doctor if Comtan is right for you. Comtan is funded under special criteria and doctor’s charges will apply. Do not take Comtan if you are pregnant, breastfeeding, have liver disease, a tumour on the adrenal gland (phaeochrom-ocytoma), severe  muscle weakness or a serious condition called neuroleptic malignant syndrome. Tell your doctor if you have severe kidney disease or are on dialysis or you are on certain medicines for depression like MAO inhibitors, warfarin or iron. Common side effects are nausea or vomiting, diarrhoea, constipation, pain in the stomach, dry mouth, dizziness, vertigo, shakiness, headache, increased sweating, difficulty sleeping, unusual dreams, feeling depressed, reddish-brown urine. Rarely sudden onset sleepiness. If symptoms persist or you have side effects see your doctor. Always read the label and use strictly as directed. Comtan is the registered trademark of Novartis AG. Novartis New Zealand Limited, Auckland.

For further information check the Consumer Medicine Information [CMI] 

The contents and information given in this website are not intended to replace the consultation and advice on your individual situation from your own doctor.
 

Last Updated: October 2010

TAPS NA1158

 Recognising and
 Managing the Signs and Symptoms
 of Wearing-Off

What is “wearing-off ?”

Over time, you may find that your symptoms begin to come back before it is time to take your next dose of medication. This change in symptoms is called “wearing-off.”

Parkinson’s disease is a slowly progressive disease, in which the symptoms get worse over time. Therefore, the symptoms you have will change and evolve. The pattern of symptoms can vary for each person. This means that everyone’s experience with the condition is different.

Fortunately, symptoms of the disease do respond well to medical treatments. One of these treatments, levodopa, has been considered the cornerstone of Parkinson’s disease therapy for nearly 40 years. It is normally very effective when it is first used to treat the disease. Over a number of years, however, some people may see changes in the way their medication controls their symptoms.
These changes are commonly known as motor fluctuations.
If you are experiencing “wearing-off,” it is important to talk to a doctor. Medications are now available that may help you manage this condition.

As “wearing-off” becomes more noticeable, you may find that the amount of time that you have a good response to levodopa (known as “on” time) shortens. The time that you have a poor response to levodopa (known as “off ” time) may lengthen. It is important to recognize when your symptoms return during the day. It could mean you are experiencing “wearing-off”. It may be possible to better control these symptoms by changing or adjusting your treatment. As these motor fluctuations emerge, other unwanted side effects may occur. These include movements you cannot control, known as dyskinesia (e.g. twisting/turning movements) or dystonia (e.g. prolonged muscle cramping).

Why do motor fluctuations occur?

In the early stage of the disease, the brain is able to store enough levodopa and dopamine. This permits smoother release of dopamine in the brain. It also provides a more constant control of symptoms. However, as Parkinson’s disease gets worse, the brain has fewer cells that can take up levodopa and store it as dopamine for release when levels are low.

Because of this reduced ability to store dopamine in the brain, symptoms may return after shorter periods of time (e.g. “wearing-off”). If someone with a reduced ability to
store dopamine is given too much levodopa, it can encourage side effects (e.g. dyskinesia).

How is “wearing-off ” identified?

Because Parkinson’s disease is a movement disorder, attention has focused on problems with movement. These are known as motor symptoms. They are the
major symptoms of the disease and can be easily spotted. The tools used by doctors to identify “wearing-off” mainly focus on the return of these motor symptoms. But, you may have other symptoms when your medication “wears-off” that have nothing to
do with movement. These types of symptoms are known as non-motor symptoms. They may affect such things as thoughts, feelings and/or sense of well-being.
“Wearing-off” can include both motor and non-motor symptoms. Your doctor may not recognise the non-motor symptoms of “wearing-off” as easily as motor symptoms.
They are less obvious because you cannot see them. You can help your doctor to identify non-motor symptoms by telling him or her how and when these symptoms occur.

What symptoms are associated with “wearing-off?”

Following is a guide to some of the symptoms that you may experience with “wearing-off.” The key to identifying “wearing-off” is to note if the symptoms return before it is time for your next dose.

MOTOR SYMPTOMS Symptoms relating to movement and mobility. These can include changes in the major symptoms of Parkinson’s disease, such as: Hands shaking Trouble using your hands Trouble getting out of a chair Muscle cramping Trouble speaking General slowness General stiffness Problems with balance

NON-MOTOR SYMPTOMS Symptoms that affect thought process, feelings and sense of well-being: Anxiety Feeling restless Panic attacks Trouble breathing Insomnia or sleep disturbances Excessive sweating Trouble thinking clearly Slowness of thinking Lack of energy Aching and numbness

When are you likely to experience “wearing-off ?”

Parkinson’s disease does not affect everyone in the same way. There is no way to tell if, or when, you might experience “wearing-off.” However, nearly half of patients experience “wearing-off” within one to two years of levodopa treatment. So, if you are taking levodopa, it is important to recognize the symptoms and talk to a doctor because there is a chance this might happen to you.

Your doctor may already have determined that you were experiencing “wearing-off.” If so, he or she may have increased your medication. For example, if you are now taking more than three doses of levodopa a day, you may have begun to experience “wearing-off.”

What if you think you are experiencing “wearing-off?”

If you think you’re experiencing “wearing-off,” discuss your changing symptoms with a doctor. There are medications available that can help manage the symptoms of “wearing-off.” Your symptom control is unlikely to get better on its own. It may get worse. Once “wearing-off” is identified, different treatment can be explored. The more information you give your doctor, the more options you will have to manage your symptoms.

How is “wearing-off” treated?

If you are experiencing “wearing-off,” your doctor may look for ways to change the medication(s) you take. This may improve your response. You may have to evaluate your daily routine. You may also have to adjust the timing and dose of your medication. The doctor my add other medications or combine medications.

Treatment Options

Once in the body, molecules called enzymes break down levodopa. Unfortunately, this “breakdown” limits the amount of medication that can reach the part of the brain where it is needed. There are two main enzymes that cause the breakdown of levodopa. They are called peripheral dopa-decarboxylase (DDC) and catechol-Omethyltransferase (COMT).

Blocking these two enzymes can reduce levodopa’s breakdown. This helps the medication get where it needs to go in the brain. Soon after levodopa was introduced, a medication known as a peripheral dopa-decarboxylase (DDC) inhibitor was developed. DDC inhibitors block one of the enzymes that causes levodopa to breakdown. They make sure that more of the medication reaches where it needs to go in the brain, which can also cut down some potential side effects, such as nausea and vomiting. These side effects can occur when dopamine is at high levels in the bloodstream.

In the 1990s, another class of medication was developed known as COMT inhibitors. COMT inhibitors, such as entacapone, provide longer and smoother availability of levodopa to the brain. Combining a COMT inhibitor with levodopa can improve and lengthen the amount of time symptoms are under control. You may start to notice that your levodopa medication is not working as well as it used to. If so, share these observations with your doctor or other healthcare professional. He or she may be able to adjust your medication to provide better control of your symptoms.

What sort of information is useful to your doctor:

It is important to help your doctor decide on the best treatment for you. Provide him or her with a full report of how your medication is working, including how long it works for you. Also note any side effects. To help you talk with your doctor, keep a diary to keep track of when you take your medication.

Record this information for a few days, then share it with your doctor at your next appointment.

The types of information you can record in your diary include:

	The times of day when you take your Parkinson’s disease medications (i.e. if you take more than one medication, make sure you are specific).
	The times of day when you have good symptom control.
	Which symptoms come back during the day and when.
	What symptoms you experience at night (e.g. sleep disturbances).
	Any complications you may experience, such as dyskinesia, and their relation to when you take your medication.

Sometimes it helps to note your mealtimes. See if the times of day when you typically eat affect your symptom control. Some people find it useful to describe their symptoms with words. You might wish to write down how they affect your daily life. Use a system that you are comfortable with and that has meaning for you. A diary will help your doctor understand what happens when you are not in his or her office. It will also track your progress when your medications have been changed. Keeping a diary of your symptoms will give you an accurate, long-term record to look back on. Your doctor may also want to keep a copy of your diary in your medical file.

We have provided a questionnaire/diary card in this website for you to print out. You may want to create your own. Again, the most important thing is that you have a diary that is easy for you to use.

After taking a dose of levodopa, most people with Parkinson’s disease experience a noticeable improvement in their symptoms. Over time, however, many patients notice
that their symptoms return before it’s time for their next dose. This is called “wearing-off”. Symptoms of “wearing off” include slowness of movement, tremor, difficulty
moving in the morning and sudden muscle spasms, among others.

To inform your healthcare professional if you are experiencing any symptoms of “wearing-off”, please click here to open a pdf questionnaire for you to print and share it with your doctor.

Click here to download your free Adobe Reader.

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