PARKINSON’S DISEASE: SUPPORTING PATIENTS WITH MOTOR AND NON-MOTOR SYMPTOMS
Faculty:
L. Austin Fredrickson, MD, FACP
L. Austin Fredrickson is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care.
Liz Fredrickson, PharmD, BCPS
Liz Fredrickson, PharmD, BCPS, is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy, where she is course director of the Parenteral Products and Basic Pharmaceutics Lab courses.
Kristina (Tia) Neu, RN
Kristina (Tia) Neu is a licensed Registered Nurse and author currently developing in-service training for healthcare professionals. She is a National Board-Certified Health & Wellness and Lifestyle Medicine Coach. Her work experience includes several areas of the healthcare profession, such as psychiatric nursing, medical nursing, motivational health coaching, chronic case management, dental hygiene, cardiac technician, surgical technician, and clinical director of a Clinically Integrated Network (CIN).
Pamela Sardo, PharmD, BS
Pamela Sardo, PharmD, BS, is a freelance medical writer and licensed pharmacist. She is the founder and principal at Sardo Solutions in Texas. Pam received her BS from the University of Connecticut and her PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, and managed health care responsibilities across a broad range of therapeutic classes and disease states.
Abstract
Parkinson’s disease is the fastest-growing neurodegenerative disorder. Motor symptoms, such as bradykinesia, tremor, and rigidity, are common. Non-motor symptoms such as constipation, orthostatic hypotension, and sleep disorders also affect a patient’s quality of life. Differentiating motor and non-motor symptoms, recognizing key medications, and understanding side effects result in optimized patient care. Identifying opportunities to improve medication adherence and safety results in effective care management. Supporting optimal management of Parkinson's disease and enhancing patient counseling directly impacts the effectiveness of the healthcare team.
Accreditation Statements
In support of improving patient care, RxCe.com LLC is jointly accredited by the Accreditation CouncilTM for Continuing Medical Education (ACCME®), the Accreditation Council for Pharmacy Education (ACPE®), and the American Nurses Credentialing Center (ANCC®), to provide continuing education for the healthcare team.
Joint Universal Activity Number: The Joint Accreditation Universal Activity Numbers assigned to this activity are as follows:
Pharmacy Technicians: JA4008424-0000-26-067-H01-T
Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit.
Credit Types:
Pharmacy - 2 Credits
Type of Activity: Knowledge
Media: Computer-Based Training (i.e., online courses)
Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Activity Pre-Test, Post-Test, and Activity Evaluation.
Release Date: May 16, 2026 Expiration Date: May 16, 2029
Target Audience: This educational activity is for Pharmacy Technicians
How to Earn Credit: From May 16, 2026, through May 16, 2029, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Take the “Educational Activity Pre-Test;”
Study the section entitled “Educational Activity;” and
Complete the Educational Activity Post-Test and Activity Evaluation. The Educational Activity Post-Test will be graded automatically. Following successful completion of the Educational Activity Post-Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
CE and CME Credits: Credit for this course will be uploaded to CPE Monitor® for pharmacists and pharmacy technicians. Physicians may receive AMA PRA Category 1 Credit™️ and use these credits toward Maintenance of Certification (MOC) requirements. Physician Assistants may earn AAPA Category 1 CME credit, reportable through PA Portfolio. All learners shall verify their individual licensing board’s specific requirements and eligibility criteria.
Statement of Need
Despite significant advances in the management of Parkinson’s disease, motor symptoms and non-motor symptoms can be undertreated and underrecognized. This gap contributes to reduced quality of life, increased healthcare utilization, and increased burden to caregivers. Pharmacy technicians are ideally positioned to support medication adherence, identify wearing-off phenomena, and to recognize side effects. Suboptimal confidence in distinguishing motor versus non-motor symptoms remains. Understanding complex Parkinson’s disease regimens is needed. This activity aims to address these practice gaps with evidence-based knowledge to optimize safety and to improve adherence to treatment.
Learning Objectives: Upon completion of this educational activity, participants should be able to:
Differentiate common motor and non-motor symptoms of Parkinson’s disease (PD)
Recognize key medications and side effects used in PD management
Identify opportunities to support adherence and patient care
Disclosures
The following individuals were involved in planning, developing, and/or authoring this activity: L. Austin Fredrickson, MD, FACP; Kristina (Tia) Neu, RN; and Pamela Sardo, PharmD, BS. None of the individuals involved in developing this activity has a conflict of interest or financial relationships related to the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.
© RxCe.com LLC 2026: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.
Educational Activity Pre-Test
Which of the following is an example of a non-motor symptom of Parkinson’s disease?
Resting tremor
Bradykinesia
Constipation
Rigidity
Which class of medications used in Parkinson’s disease is most commonly associated with impulse control disorders?
COMT inhibitors (e.g., entacapone)
Dopamine agonists (e.g., pramipexole, ropinirole)
MAO-B inhibitors (e.g., rasagiline)
Amantadine
A patient with Parkinson’s disease takes carbidopa/levodopa. The patient reports frequently feeling “stiff and slow” in the late afternoon and often runs out of medication a few days early. What is the most appropriate action?
Advise the patient to take an extra dose when symptoms return
Inform the pharmacist about possible “wearing off” symptoms and early refill requests
Recommend taking the medication with a high-protein meal to improve absorption
Tell the patient these symptoms are normal and nothing can be done
Educational Activity
Parkinson's Disease: Supporting Patients with Motor and Non-Motor Symptoms
Introduction
Parkinson’s disease (PD) is a chronic, progressive neurodegenerative disorder that affects movement and many other body functions. It is the fastest-growing neurodegenerative disease worldwide.1 Parkinson’s disease causes both motor symptoms and non-motor symptoms. These symptoms can significantly affect the quality of life for patients and caregivers. Pharmacy technicians play an important role in ensuring patients receive the right medications on time, answering basic questions, noticing potential adherence issues or side effects, and helping connect patients with pharmacists and other healthcare professionals.
Epidemiology
Parkinson’s disease currently affects about 572 per 100,000 adults over age 45.1-3 It is expected to impact more than 12 million people globally by 2040.2,3 The disease is more common in men (about 2:1 ratio), but women may experience more dyskinesia, depression, and urinary issues. Risk increases strongly with age. Most diagnoses occur after age 65, though 5-10% are diagnosed before age 50.2 The increase in incidence and prevalence likely stems from factors such as population aging, improved diagnostic accuracy, and prolonged survival. Disparities exist across racial and ethnic groups, and higher rates in industrialized areas point to possible environmental influences. Early recognition and team-based care can improve outcomes.
Causes and Risk Factors
The exact cause of PD remains unknown. Most PD cases result from a combination of genetic and environmental factors. Only a small percentage are purely genetic (monogenic), but variants like GBA increase risk, especially in certain populations, such as those of Ashkenazi Jewish or North African ancestry.2,4
Exposure to certain environmental toxins is linked to a higher risk of PD. These exposures include pesticides, solvents, and heavy metals.1,2 Traumatic brain injury later in life may also be a contributor.2 Lifestyle factors such as physical activity, coffee/tea consumption, and diet may influence risk.1-2
The disease involves the loss of dopamine-producing neurons in the substantia nigra and the abnormal buildup of the alpha-synuclein protein in Lewy bodies.5 Pathology may start in the gut or olfactory system and spread to the brain.5 Inflammation also plays a role.6
Prodromal Phase
Parkinson's disease typically begins with a prodromal phase. This is the period before the onset of motor symptoms, when individuals may experience various non-motor symptoms. Patients may experience non-motor symptoms for years or even decades before classic movement problems appear.2 Common early non-motor signs include the following:1,2,7,8
Loss of smell (hyposmia)
REM sleep behavior disorder (acting out dreams)
Constipation
Depression or anxiety
Urinary issues
Orthostatic hypotension (dizziness upon standing)
By the time motor symptoms appear, up to 75% of dopamine neurons may already be lost.1 Pharmacy staff can help by listening to patients describe what may sound like “vague” complaints and alerting the pharmacist.
Motor Symptoms
Patients with PD experience motor symptoms during ‘On’ time and ‘Off’ time. The ’On’ time is when the symptoms are controlled with medication. The ‘Off’ time is when symptom-free periods shorten and the incidence of dyskinesia increases.
Motor symptoms are the hallmark of PD. The four cardinal motor symptoms are:3,6
Bradykinesia: Slowness and smallness of movement. Patients may have trouble starting movements or notice handwriting getting smaller.
Resting tremor: Rhythmic shaking that typically occurs when the affected limb is completely relaxed, referred to as pill-rolling. It is often asymmetric. It usually decreases with intentional movement.
Rigidity: An increased muscle tone and resistance to passive movement. It appears as stiff muscles with “lead-pipe” or “cogwheel” resistance on passive movement.
Postural instability — Poor balance, stooped posture, shuffling gait, festination (short, rapid steps), and increased fall risk. This usually appears later in time as the condition progresses.
Other motor issues include hypomimia (masked face), dysarthria (soft or slurred speech), dysphagia (swallowing difficulty), and dystonia (muscle cramps).
Non-Motor Symptoms (NMS)
The burden of NMS is considerable. These symptoms are linked to lower quality of life, increased caregiver stress, higher rates of hospitalization and institutionalization, and worse overall health outcomes.9,10 In many cases, symptoms such as fatigue, pain, or anxiety may have a greater impact on daily life than tremor or stiffness. Non-motor symptoms affect almost all patients.9,10 They can fluctuate with medication timing (“on” vs “off” periods) or remain constant. Despite their impact, NMS often go unrecognized. This may occur because patients do not report them, or because clinicians attribute them to aging, medication side effects, or other chronic conditions.2 Lack of awareness about the significance of these symptoms in PD remains a barrier to care.
Categories include the following:
Autonomic9,11,12
Can affect multiple organ systems
Constipation (very common, can precede diagnosis)
Orthostatic hypotension (dizziness, falls)
Urinary urgency/frequency/nocturia
Drooling (sialorrhea)
Sexual dysfunction
Sweating or temperature regulation problems
Psychiatric10
Depression and anxiety
Apathy, loss of motivation
Psychosis/hallucinations (can be medication-related)
Impulse control disorders (such as compulsive gambling or shopping, which is often linked to dopamine agonists)
Cognitive10
Mild cognitive impairment (common at diagnosis)
Dementia (risk rises with disease duration)
Sleep13
Insomnia
REM sleep behavior disorder
Excessive daytime sleepiness
Restless legs syndrome
Other11,12,14
Pain (musculoskeletal, dystonic, central)
Fatigue
Hyposmia
Weight loss
Pause and Ponder Which non-motor symptoms associated with Parkinson’s disease have you seen in your patients? Which treatments are being prescribed for those non-motor symptoms? |
|---|
Diagnosis
Parkinson’s disease is diagnosed clinically using the Movement Disorders Society (MDS) criteria.15 Physicians look for typical motor features, such as asymmetric bradykinesia plus tremor or rigidity, then check for supportive features. The supportive features are additional features, such as a good response to levodopa, hyposmia, and REM sleep behavior disorder.15
Physicians also rule out signs that may indicate an alternative diagnosis. Red flags or exclusions include rapid progression, early severe autonomic issues, or medication-induced parkinsonism.15 No single test is available to confirm PD in life; so the physician’s expert opinion, or occasionally imaging or smell tests, may help in uncertain cases.
Pharmacologic Management for Motor Symptoms
A multi-pronged approach for patients, with pharmacological and non-pharmacological interventions, is important because each patient's clinical presentation is unique and symptom onset varies. Managing the symptoms of PD presents a challenge to physicians because identifying the symptoms, differentiating possible contributions from medication, and uncovering the patient’s emotional state are required.16 There is no cure, but medications manage symptoms. A multi-pronged approach for patients, with pharmacological and non-pharmacological interventions, is important because each patient's clinical presentation is unique and symptom onset varies. Medications will not cure PD or slow its progression, but one goal that can be achieved is replacing a patient’s lost dopamine. This can help manage the debilitating motor symptoms caused by PD.
There are multiple options that may be used to replace a patient’s lost dopamine: levodopa (also known as L-DOPA), a dopamine precursor (prodrug); a dopamine receptor agonist; or a monoamine oxidase type B inhibitor.17,18 These options may provide initial benefit for motor symptoms.17,18 Carbidopa-levodopa is the gold standard medication.17 Carbidopa and levodopa have very short half-lives, so medication timing is very important. The efficacy of long-acting medications is similar to that of immediate-release dosage forms.
Daily regimens and doses are highly variable and must be individualized to maximize efficacy and minimize adverse effects. Considering genetic factors, some genes are associated with a good response to levodopa, whereas others are associated with a poor, variable, or uncertain response in individuals with PD.19 Always consult the full prescribing information for each medication for comprehensive safety and efficacy information. Some commonly prescribed treatments are listed in the tables below.
Table 1
Common Levodopa-Containing Medications
for Motor Symptoms 20-25
| Select Agents | Typical Dose | Common Adverse Effects |
|---|---|---|
| Carbidopa and levodopa tablet (immediate-release), ODT (oral disintegrating tablets) | Individualize up to 200/2,000 mg daily in divided doses | Nausea, loss of appetite, lightheadedness, confusion, dyskinesias, hallucinations, impulsivity |
| Carbidopa and levodopa (extended-release) | Individualize up to 525/2,100 mg daily | Nausea, loss of appetite, lightheadedness, confusion, dyskinesias, hallucinations, impulsivity |
| Carbidopa and levodopa enteral suspension | Individualize to 2,000 mg of levodopa over 16 hours | Nausea, loss of appetite, lightheadedness, confusion, dyskinesias, hallucinations, impulsivity, gastrointestinal or insertion complications |
| Foscarbidopa/foslevodopa subcutaneous injection | Individualize up to 3,525 mg foslevodopa (approximately 2,500 mg levodopa) (preferably in the abdomen via pump) | Nausea, loss of appetite, lightheadedness, confusion, dyskinesias, hallucinations, impulsivity, infusion/catheter site reactions |
| Carbidopa-levodopa-entacapone | Individualize up to 1200 mg levodopa daily. Experience with daily doses above 1600mg of entacapone is limited | Nausea, loss of appetite, lightheadedness, confusion, dyskinesias, hallucinations, impulsivity, urine discoloration, diarrhea, and abdominal pain |
| Levodopa inhalation powder | Max dose per OFF period is 84 mg. Max daily dosage is 420 mg by inhalation only | Max dose per OFF period is 84 mg. Max daily dosage is 420 mg by inhalation only |
Table 2
Common Dopamine Agonists for Motor Symptoms26-31
| Select Agents | Typical Dose | Common Adverse Effects |
|---|---|---|
| Pramipexole | Individualize up to 4.5 mg daily by week 7 | Nausea, dizziness, somnolence, insomnia, constipation, asthenia, hallucinations |
Pramipexole Dihydrochloride (extended-release) | Individualize up to 4.5 mg | Somnolence, nausea, constipation, dizziness, fatigue, hallucinations, dry mouth, muscle spasms, and peripheral edema |
| Ropinirole | Individualize dose, titrate to a maximum daily dose of 24 mg | Nausea, somnolence, dizziness, syncope, leg edema, vomiting, dyskinesia, hallucination, sweating |
| Ropinirole (extended-release) | Individualize dose up to a maximally recommended dose of 24 mg/day | Somnolence, abdominal pain/discomfort, dizziness, headache, constipation, dyskinesias, hallucination, abdominal pain/discomfort, and orthostatic hypotension |
| Apomorphine hydrochloride injection | For intermittent use. Individualize and titrate to effect and tolerance. The maximum recommended dose is 0.6 mL. Pretreat with an antiemetic 3 days before initiation, but for no longer than 2 months | Yawning, drowsiness, somnolence, dyskinesias, postural hypotension, rhinorrhea, nausea, vomiting, hallucination, confusion, edema/swelling |
| Rogitotine transdermal system | Individualize dose, applied to the skin, up to 6 mg/24 hours for early-stage disease and up to 8 mg/24 hours for advanced-stage disease | Nausea, vomiting, somnolence, application site reactions, dizziness, anorexia, sleep disturbances, hyperhidrosis, visual disturbance, peripheral edema, dyskinesia |
Table 3
Common Amantadine Formulations for Motor Symptoms32,33
| Select Agents | Typical Dose | Common Adverse Effects |
|---|---|---|
| Amantadine* | 200 mg daily, which may be split into 100 mg twice daily. A suboptimal response may increase to 400 mg daily with close supervision | Nausea, insomnia, Blurry vision and/or impaired mental acuity, dizziness, depression, hallucination, lightheadedness, mood changes |
| Amantadine ER (extended-release) capsules* | Individualize and increase to the recommended daily dosage of 274 mg | Hallucination, dizziness, dry mouth, peripheral edema, constipation, falls, and orthostatic hypotension |
*Amantadine is facing ongoing, prolonged shortages
Table 4
Additional Select Pharmaceutical Agents for Motor Symptoms34-43
| Select Agents | Typical Dose | Common Adverse Effects |
|---|---|---|
| Adenosine Receptor Antagonists | ||
| Istradefylline | Individualize up to a maximum of 40 mg once daily | Dyskinesia, dizziness, constipation, nausea, hallucination, and insomnia |
| Monoamine Oxidase-B (MAO-B) Inhibitors | ||
| Selegiline (oral disintegrating tablets) | Individualize up to 2.5 mg once a day | Constipation, skin disorders, vomiting, dizziness, dyskinesia, insomnia, dyspnea, myalgia, rash |
| Rasagiline | Individualize up to 1 mg once daily | Flu, arthralgia, depression, dyspepsia, falls, headache, hallucination, dizziness, diarrhea |
| Safinamide | Individualize up to 100 mg once daily | Dyskinesia, falls, nausea, insomnia, hypertension, serotonin syndrome, hallucination, impulse control |
| Catechol-O-methyltransferase (COMT) Inhibitors | ||
| Entacapone | Administer concomitantly with each levodopa-carbidopa dose to a maximum of 1600 mg daily | Dyskinesia/hyperkinesia, nausea, urine discoloration, diarrhea, abdominal pain |
/// Tolcapone | /// Administer concomitantly with levodopa-carbidopa dose to the recommended 100 mg tid. Use 200 mg only if the benefit is justified due to adverse effects | /// Hepatocellular injury, dyskinesia, nausea, sleep disorder, anorexia, muscle cramps, orthostatic complaints, dizziness, hallucination |
| Opicapone | Recommended dosage is 50 mg orally once daily at bedtime | Arrhythmia, increased heart rate, syncope, dyskinesia, sleepiness, hallucination, impulse control |
| Anticholinergics | ||
| Benztropine | Individualize orally to 1 to 2 mg, 0.5 mg to 6 mg parenterally daily | Gastrointestinal complaints, anhydrosis, and cumulative action may lead to tachycardia, dysuria, weakness, confusion, and hallucination |
| Trihexyphenidyl tablets or solution | Individualize to the maximum dose of 12 to 15 mg daily | Intraocular pressure change, anhidrosis, dry mouth, dizziness, nausea, nervousness, hallucination |
Treatment Options for Non-Motor Symptoms
Table 5 provides treatment options for a broad range of NMS.1,3,16,44,45
Table 5
Pharmacologic and Non-pharmacologic Management of Non-motor Symptoms in Parkinson’s Disease
| NMS Symptom | Non-Pharmacologic Therapies | Pharmacologic Therapies |
|---|---|---|
| Neuropsychiatric Symptoms | ||
| Depression/Anxiety | CBT, exercise, social support, mindfulness-based stress reduction, mindfulness-based cognitive therapy, Qigong, dance, and music therapy | • SSRI: citalopram, escitalopram, paroxetine, fluoxetine, or sertraline • SNRIs: venlafaxine • TCA: desipramine, nortriptyline • Benzodiazepines: clonazepam (panic disorder) |
| Apathy | CBT, music therapy | • AChEI: rivastigmine • Piribedil, a D2/D3 dopamine agonist |
| Psychosis - Hallucinations/Delusions | Environmental modifications, caregiver support, and reduce nighttime stimulation | • Pimavanserin, a serotonin 5-HT 2A/C inverse agonist and antagonist • AChEI: rivastigmine, donepezil • NMDA antagonist: memantine |
/// Impulse Control and Related Disorders | /// Psychoeducation, CBT, caregiver support | /// • Reduce dopamine agonists • Amantadine (conflicting evidence) |
| Cognition Impairment/Dementia | Cognitive training, mental stimulation, sleep optimization, dance, and music therapy | AChEI: rivastigmine, donepezil (off-label) NMDA antagonist: memantine (off-label) |
| Autonomic Symptoms | ||
| Orthostatic Hypotension | Dietary modifications (increased salt), hydration, compression garments, physical exercise, and elevate the head of bed | • Mineralocorticoid: fludrocortisone • AChEI: pyridostigmine • NE precursor: droxidopa • NRI: ampreloxetine • Review antihypertensives, diuretics, and PD medication |
| Lower Urinary Tract Symptoms | Scheduled voiding, pelvic floor exercises | • Antimuscarinic: oxybutynin, trospium • Beta-3 agonist: mirabegron • Botulinum toxin |
| Sexual Problems | Schedule sexual activity when medications are working best | • PDE5 inhibitor for ED: sildenafil • Female decreased libido and dryness: HRT, estrogen cream, lubrication |
/// Constipation | /// Hydration, fiber, small meals, regular exercise | /// • Fiber supplements: psyllium • Laxatives: polyethylene glycol, bisacodyl • Probiotics • Secretagogue: lubiprostone • 5-HT4 agonist: prucalopride |
| Sialorrhea (Drooling) | Posture, chewing gum, and reminders to swallow | • Botulinum toxin • Anticholinergics: glycopyrrolate sublingual atropine drops, ipratropium bromide spray |
| Sleep and Related Disorders | ||
| REM Sleep Behavior Disorder | Sleep hygiene, sleep environment safety modifications, and treatment of comorbid sleep disorders | • Melatonin • Benzodiazepines: clonazepam |
| Insomnia | CBT-I (first line), regular exercise, sleep hygiene, avoid naps and caffeine late in the day | • Sedative-hypnotics: eszopiclone, zolpidem, zaleplon • Melatonin • Antidepressants: doxepin, trazodone |
| Excessive Daytime Sleepiness | Activity pacing, bright light therapy, and physical activity | • Stimulants: methylphenidate, modafinil • Caffeine |
| Fatigue | Energy conservation techniques, Qigong, short naps in early afternoon, regular exercise, hydration, and address underlying contributors | • Stimulants: modafinil, methylphenidate • MAO-B inhibitors: safinamide, rasagiline • Antidepressant: doxepin |
| Other | ||
| Musculoskeletal Pain | Exercise, stretching, PT, massage, hot/cold therapy, yoga | • Analgesics: acetaminophen, NSAIDs • Adjust PD medications |
| Neuropathic Pain | Mindfulness, TENS (transcutaneous electrical nerve stimulation), PT, CBT | • Gabapentin, pregabalin • Antidepressants: duloxetine, amitriptyline, venlafaxine |
| Dystonic Pain | Stretching, PT, acupuncture, and massage | • Botulinum toxin • Optimize levodopa timing • Anticholinergics: trihexyphenidyl, benztropine |
| Central Pain | Meditation, distraction techniques, exercise, CBT, sleep optimization | • Dopaminergic therapy • NMDA antagonist: amantadine • Antidepressants: TCAs, SSRIs, SNRIs |
AChEI, acetylcholinesterase inhibitor; CBT, cognitive behavioral therapy; ED, erectile dysfunction; HRT, hormone replacement therapy; NRI, ;OAB, overactive bladder; PT, physical therapy; SNRIs, selective serotonin–norepinephrine reuptake inhibitors; SSRIs, selective serotonin-reuptake inhibitors; TCAs, tricyclic antidepressants
Treatment options for PD continue to expand. There are advanced treatments as the disease progresses and symptoms become more complex or severe. These may include deep brain stimulation (DBS), focused ultrasound, levodopa intestinal gel, or apomorphine infusion.
Preventing Medication Side Effects
The most effective way to prevent side effects while maintaining the quality of life in patients with PD is to consider medication choices and avoid certain drug interactions carefully.
Avoiding dopamine-blocking medications such as metoclopramide, prochlorperazine, and promethazine.
Use certain pain medications with caution. While sometimes necessary, meperidine, tramadol, and methadone can interact with MAO-B inhibitors.
Interactions with MAO-B inhibitors are also contraindicated when combined with sympathomimetic drugs such as phenylpropanolamine or ephedrine.
Dietary restrictions with MAO-B inhibitors. Avoid foods high in tyramine, such as aged cheeses, red wine, and herring.
Non-Pharmacologic Management
Medications are only part of the care provided to these complex patients. Current pharmacological treatments for PD, while offering some relief, often leave patients with significant unmet needs, especially regarding specific motor symptoms like freezing of gait and postural instability. These limitations have increased interest and research into non-pharmacological approaches to managing PD.47 These interventions play an important role in improving quality of life, maintaining function, and promoting overall well-being for individuals with PD.
Multidisciplinary approaches are ideal:48-52
Physical Therapy/Exercise: Aerobic, strength, balance, gait training. Tai Chi, dance, boxing. Aim for regular moderate-high intensity activity.
Occupational Therapy: Adaptive equipment, home safety, daily activity strategies.
Speech Therapy: Specialized exercises and strategies like Lee Silverman Voice Treatment (LSVT LOUD) to increase voice loudness, and swallowing exercises to prevent aspiration.
Nutrition: Mediterranean/MIND diet, protein, hydration, fiber for constipation.
Mental Health: CBT, support groups, mindfulness.
Other: Music/dance therapy, yoga, community exercise programs.
Taking levodopa with a high-protein meal can interfere with its absorption in the gut. Protein redistribution diets are a dietary strategy that helps to manage this interaction. These diets don’t restrict overall protein intake but aim to optimize the timing of protein consumption. These approaches improve motor function, mood, sleep, constipation, and quality of life.
Patient Handouts Parkinson's Exercise Recommendations: handout from the Parkinson’s Foundation: https://www.parkinson.org/library/fact-sheets/exercise-recommendations Nutrition and Parkinson's Disease: handout from the Parkinson’s Foundation: https://www.parkinson.org/sites/default/files/documents/nutrition-2022.pdf |
|---|
Patient-led behaviors play a key role in managing NMS. These strategies can be initiated independently or with guidance from a health professional.
Daily routine supports sleep regulation and improves medication effectiveness2
Sleep hygiene includes consistent sleep and wake times, a dark and quiet environment, and limiting caffeine and alcohol
Symptom tracking helps identify patterns, especially non-motor fluctuations8
Light physical activity supports mood, sleep, and fatigue9
Mindfulness or relaxation practices help reduce anxiety and improve sleep10
Hydration and dietary fiber support bowel regularity and help manage orthostatic symptoms12,52
Social connection improves motivation and may reduce fatigue and cognitive decline9
Mobile apps or journals can reinforce routines and improve adherence to self-care plans8
Clear, consistent encouragement from the care team can help patients feel confident in adopting these practices.
Role of Pharmacy Technicians in Parkinson’s Disease Care
Ensure accurate filling, and remind the patient and family to pick up their refills on time, as many medications require strict timing. Apply the auxiliary labels that emphasize this tip.
Keep sufficient quantities of chronic medication in stock.
Monitor for drug shortages.
There are many strengths of the same medication, so accurate prescription processing is critical.
Use open-ended questions: “How are the medications working?”
Educate the patient and family on administration.
Apply the appropriate auxiliary label. One example is to remind the patient to take levodopa on an empty stomach
Identify and flag potential issues to refer to the pharmacist. These include missed doses, possible confusion, uncontrolled movements, orthostatic symptoms, and constipation.
The family may ask about support groups.
Help caregivers with medication organization tools, such as pill boxes and alarms.
Case Study 1: Motor Symptoms
Mrs. Smith, 58, picks up her refill prescription for carbidopa-levodopa. She mentions that her balance has worsened and she has had several recent falls. What is a possible next step?
The patient’s statement and recent falls are red flags. The pharmacy technician should immediately inform the pharmacist, who can then contact the prescriber to determine whether the symptoms are due to resistance to standard dopamine replacement therapies such as carbidopa-levodopa, medication-induced orthostatic hypotension, or another cause. Early recognition is important to begin determining the possible cause.
Case Study 2: Non-Motor Symptoms
Mr. T brings in prescriptions and reports discomfort from constipation and a loss of smell; he saw smoke but could not smell it when he burned his microwave popcorn. He admits he feels tired. What action should be taken?
Rather than sharing the location of over-the-counter laxatives, document these symptoms and alert the pharmacist. The clinic team later suspects prodromal PD and starts appropriate supportive care.
Summary
Parkinson’s disease involves complex motor and non-motor symptoms that require lifelong, individualized, team-based care. Pharmacy technicians contribute by supporting medication safety and adherence and by recognizing red-flag symptoms to refer to the pharmacist. Attaching important auxiliary labels and sharing resources helps the patient. Because each patient has unique symptoms, encourage patients to ask their doctor or pharmacist any questions they may have. Facilitating communication with pharmacists and other interprofessional team members is important. Attention to detail and compassionate interactions make a real difference in patients’ daily lives.
References
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Kalia LV, Lang AE. Parkinson's disease. Lancet. 2015;386(9996):896-912. doi: 10.1016/S0140-6736(14)61393-3
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CARBIDOPA AND LEVODOPA tablet, orally disintegrating. Prescribing Information. Sun Pharmaceutical Industries, Inc. Updated December 9, 2024. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=48e0f2ec-b217-4c25-a71c-20e173d05edb
CREXONT- carbidopa and levodopa capsule, extended release. Prescribing Information. Amneal Pharmaceuticals LLC. Updated March 20, 2026. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=095a08b6-b0b8-4f88-b759-67e8b87287a0
DUOPA- carbidopa and levodopa suspension. Prescribing Information. AbbVie Inc. Updated March 19, 2026. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7066d371-dc6a-0d6f-7bed-e5dd4ee912da
VYALEV- foscarbidopa/foslevodopa injection. Prescribing Information. AbbVie Inc. Updated March 19, 2026. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=28e806e4-951c-40a9-9f0c-d0929caf054c
CARBIDOPA, LEVODOPA AND ENTACAPONE tablet, film coated. Prescribing Information. Alembic Pharmaceuticals Inc. Updated February 25, 2026. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9d4e886e-edec-471d-b619-bf4828a6b7ce
INBRIJA- levodopa capsule. Prescribing Information. Merz Pharmaceuticals, LLC. Updated September 22, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=077c0f39-a3a2-4b2b-a184-09131889dcfb
PRAMIPEXOLE DIHYDROCHLORIDE tablet. Prescribing Information. Alembic Pharmaceuticals Inc. Updated November 12, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4fe7106d-4bf6-4794-87cb-8df616994c41
PRAMIPEXOLE DIHYDROCHLORIDE EXTENDED-RELEASE- pramipexole dihydrochloride tablet, extended release. Prescribing Information. Xiamen LP Pharmaceutical Co., Ltd. Updated June 16, 2021. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1cbd8ddf-4fc1-4cd0-906d-a55a4b8b1c3c
ROPINIROLE HYDROCHLORIDE tablet, film coated. Prescribing Information. SOLCO HEALTHCARE US, LLC. Updated May 30, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7734ef0b-584f-42dd-a8b5-adbdf4e4df93
ROPINIROLE tablet, extended release. Prescribing Information. Elite Laboratories, Inc. Updated November 10, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=307411be-1c4e-44f7-b94d-737a3384c107
APOKYN- apomorphine hydrochloride injection. Prescribing Information. MDD US Operations, LLC. Updated October 10, 2024. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3235535d-9ef9-4657-8b2a-176a807d091c
NEUPRO- rotigotine patch, extended release NEUPRO- rotigotine kit. Prescribing Information. UCB, Inc. Updated June 24, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=939e28c5-f3a9-42c0-9a2d-8d471d82a6e0
GOCOVRI- amantadine capsule, coated pellets. Prescribing Information. Supernus Pharmaceuticals. Updated February 16, 2026. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2bee0631-0028-1314-e063-6394a90aaaed
AMANTADINE capsule. Prescribing Information. Alembic Pharmaceuticals Inc. Updated June 4, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4157d9a7-a53f-4dde-b051-fe3e9a674913
NOURIANZ- istradefylline tablet, film coated. Prescribing Information. Kyowa Kirin, Inc. Updated May 20, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a7d008cb-b273-4049-a5d2-9c6902910d58
ZELAPAR- selegiline hydrochloride tablet, orally disintegrating. Prescribing Information. Bausch Health US, LLC. Updated June 1, 2021. Accessed May 14, 2026.
RASAGILINE MESYLATE tablet. Prescribing Information. Avet Pharmaceuticals Inc. Updated December 30, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7d070521-ea04-4483-bdb9-54a8859700df
XADAGO- safinamide mesylate tablet, film coated. Prescribing Information. MDD US Operations LLC, a subsidiary of Supernus Pharmaceuticals, Inc. Updated October 22, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c4d65f28-983f-42b4-bb23-023ae0fe81b2
ENTACAPONE tablet. Prescribing Information. Ajanta Pharma USA Inc. Updated October 1, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e9e94e9f-cd7a-45f5-9aeb-9c28ed804d8c
TOLCAPONE tablet, film-coated. Prescribing Information. Oceanside Pharmaceuticals. Updated October 1, 2020. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=dd367eec-359a-4065-b5c3-7c0107c823fe
ONGENTYS- opicapone capsule. Prescribing Information. Amneal Pharmaceuticals LLC. Updated October 15, 2025. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a511a531-112e-43f8-a43f-5334b0efe979
BENZTROPINE MESYLATE- benztropine tablet. Prescribing Information. Cipla USA Inc. Updated May 1, 2020. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3d2732f9-b8a9-4e83-91e7-da616ddcb786
TRIHEXYPHENIDYL HYDROCHLORIDE tablet. Prescribing Information. Actavis Pharma, Inc. Updated February 2, 2024. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a44d7803-164d-4a67-9356-581c45de8596
TRIHEXYPHENIDYL HYDROCHLORIDE solution. Prescribing Information. PAI Holdings, LLC dba PAI Pharma. Updated November 19, 2024. Accessed May 14, 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9036c9f0-6d2d-4d0f-a20e-e36f9be228f7
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