Q: Levodopa, Carbidopa (tidomet), Selgin and Pacitane are used for the treatment of Parkinson's. My father is suffering from Parkinson's since 4 years and is taking tidomet (levodopa 100 mg) and carbidopa 10 mg and pacitane only. The doses are 1/2 tablet tidomet 3 times a day and pacitane 1/2 tablet 3 times a day. Now, this is not controlling the symptoms. The doctor told us to increase the dose to one tablet of tidomet 3 times a day and reduce pacitane 1/2 tablet to 2 times only and adding selgin 5 mg. Should we start this? He feels a lot of stiffness.

A:Your father's Parkinsonism is relatively of short duration; hence every attempt should be made to control his signs and symptoms with minimum medication. The dose of various medicines used in Parkinsonism needs to be titrated in each patient individually. One patient may respond while another may not to the same dosage schedule. Similarly one patient may need levodopa/carbidopa in the ratio of 10:1 while another patient may need it in 4:1 ratio. It is because of this reason that there are various combinations of levodopa/carbidopa in the market such as 100 mg: 10 mg, 250 mg:25 mg and 100 mg:25 mg. Most patients require about 75 mg of carbidopa. In your father's case, the dose being given is 150 mg of levodopa with 15 mg of carbidopa. This is apparently not adequate. Maximum permitted is 2000 mg of levodopa with 200 mg of carbidopa. Similarly one can also give a maximum of 800 mg of levodopa with 200 mg of carbidopa by using 100 (levodopa): 25 (carbidopa) formulation. Hence one should titrate the dose upward to see the effect before adding other agents such as selegiline so as to avoid side effects. Apart from the need to give minimum number of medicines in full dose, there is some evidence that overall mortality increases when selegiline is added. That is not to say that selegiline should not be given at all but only when other medicines fail to provide adequate response when used in adequate dose. Titration is not easy but there is no easy way out.