Levodopa

Key Facts

  • The central objective of using Parkinson’s disease medication is to control or manage motor symptoms.
  • Almost all patients will need levodopa in their management.
  • In general it is recommended that you start with a dopamine agonist if your patient is younger than 50 years; you should consider starting with carbidopa/levodopa if your patient is older than 70 years; either option is good if your patient is between 50 and 70 years old.
  • All patients will eventually need levodopa in their therapeutic regimen as their PD progresses.

Clinical Best Practices

  • Levodopa should be titrated to severity of symptoms over several weeks (see prescription recommendations below).

Levodopa is still the most effective medication available for treatment of motor symptoms in PD. All patients will eventually need levodopa in their therapeutic regimen as their PD progresses.  Levodopa is a first-line medication for PD.

Presentation

 

Dosages in Milligrams

Typical Treatment Regimens

Indications for Usage

Carbidopa/levodopa

immediate-release

(Sinemet)

10/100,

25/100,

25/250

150–1000 mg of  levodopa total daily dose (divided 3-4 times)

Monotherapy or adjunct therapy for slowness, stiffness, and tremor

Carbidopa/levodopa oral disintegrating

(Parcopa)

10/100,

25/100,

25/250

150–1000 mg of  levodopa total daily dose(divided 3-4 times)

Same as above, plus need for dissolvable medication in mouth

Carbidopa/levodopa  extended-release

(Sinemet CR)

25/100,

50/200

150–1000 mg of levodopa total daily dose, (divided 2-4 times)

Monotherapy or adjunct therapy for slowness, stiffness, and tremor

Carbidopa/levodopa/entacapone

(Stalevo)

 

12.5/50/200,

18.75/75/200,

25/100/200,

31.25/125/200,

37.5/150/200,

50/200/200

150–1000 mg of levodopa total daily dose, dosed 2–3 times/day (divided 3-4 times)

Replacement for carbidopa/levodopa, for motor fluctuations (benefit of entacapone)

Levodopa/benserazide hydrochl

(Madopar, Prolopa)

250/50 (250mg), 100/25 (125 mg),

50/12.5 (62.5 mg)

187.5–1000 mg total daily dose (divided 3-4 times)

Not available in US.

 

Prescription Recommendations

  • Prescribe:  carbidopa/levodopa 25/100 (tablet)
  • Instruct: ½ tab tid for one week, then 1 tab tid and re-evaluate symptoms and patient clinical response at this dose. If symptoms need further treatment then titrate up to 1.5 tab tid for one week, then 2 tab tid.  (Tip: In general, titrate to severity of symptoms. Tolerance of side effects should guide therapy,and dose as well as interval may need to be adjusted; you may also sometimes need 3 tablets as well as a gastric emptying study if medication is not effective)

OR

  • Prescribe: levodopa/benserazide 50/12.5 (capsule)
  • Instruct: 1 cap tid for one week, then 2 caps tid for one week, then 3 caps tid
  • Tip: If you encounter nausea add 25-75mg of carbidopa per dose of sinemet or alternatively add domperidone
  • Levodopa/benserazide and domperidone are not available in the US

Note: Give levodopa 1 hour prior or 2 hours after meals.

Side Effects

  • Nausea, vomiting (take pills on a full stomach to reduce nausea or use domperidone 10-20 mg tid or trimethobenzamide hydrochloride 300 mg up to 4 times daily)
  • Loss of appetite
  • Orthostatic hypotension: Use lowest dose possible, improve hydration, ensure diagnosis is correct, reduce antihypertensive medications if possible, reduce alpha antagonists if possible (used to treat urinary incontinence or prostatic hypertrophy), consider midodrine (an alpha agonist) 2.5 half tab tid to start up to 15 mg tid
  • Confusion/delirium: Reduce or withdraw anticholinergic medications; reduce or stop any medications that are sedating
  • Dyskinesia
  • Constipation
  • Dry mouth
  • Headache
References: 

Ahlskog JE. Parkinson’s Disease Treatment Guide for Physicians. New York, NY: Oxford University Press; 2009.

Ahlskog JE. The Parkinson’s Disease Treatment Book: Partnering with your Doctor to Get the Most from Your Medications. New York, NY: Oxford University Press; 2005.