Levodopa nervous system

Ach, acetylcholine CNS, central nervous system CD, carbidopa COMT, catechol-O-methyltransferase D1, a class of dopamine receptors which includes D, and D5 subtypes D2, a class of dopamine receptors which includes D2, D3, and D4 subtypes DA, dopamine LD, levodopa MAO, monoamine oxidase MD, maintenance dose NMDA, N-methyl-D-aspartate. 

Dopamine is the immediate precursor in the synthesis of norepinephrine (see Figure 6-5). Its cardiovascular effects were described above. Endogenous dopamine may have more important effects in regulating sodium excretion and renal function. It is an important neurotransmitter in the central nervous system and is involved in the reward stimulus relevant to addiction. Its deficiency in the basal ganglia leads to Parkinson s disease, which is treated with its precursor levodopa. Dopamine receptors are also targets for antipsychotic drugs. 

Disposition in the Body. Rapidly absorbed from the small bowel after oral administration and widely distributed in the tissues less than 1% of a dose reaches the brain bioavailability about 33%. Extensively metabolised mainly by decarboxylation to dopamine, which is further metabolised, and also by methylation to 3-0-methyldopa which accumulates in the central nervous system most of a dose is decarboxylated by the gastric mucosa before entering the systemic circulation the decarboxylase activity is inhibited by carbidopa and benserazide. Dopamine is further metabolised to noradrenaline, 3-methoxytyramine, and to the two major excretory metabolites, 3,4-dihydroxyphenyl-acetic acid (DOPAC) and 3-methoxy-4-hydroxyphenylacetic acid (homovanillic acid, HVA). During prolonged therapy, the rate of levodopa metabolism appears to increase, possibly due to enzyme induction. About 70 to 80% of a dose is excreted in the urine in 24 hours. Of the material excreted in the urine, about 50% is DOPAC and HVA, 10% is dopamine, up to 30% is... 

Minimisation of unwanted effects. Combining levodopa with benserazide (Madopar) or with carbidopa (Sinemet) slows its metabolism outside the central nervous system so that smaller amounts of levodopa can be used this reduces adverse effects. 

Fatigue and light-headedness or dizziness have occurred relatively frequently during oral entacapone administration in small studies (up to 60% of patients) (4). Other less frequent central nervous system effects include confusion, anxiety, syncope (related to postural hypotension), and insomnia (5,6). Mood elevation has been observed occasionally (5). The inclusion of entacapone in levodopa therapy for Parkinson s disease increases the risk of dyskinesias, possibly through enhanced brain penetration of levodopa (4,5,7). This can be adjusted by reducing the dose of levodopa. 

Pyridoxine interferes with the desired nervous system effect of levodopa (64,65), since it is a co-decarboxylase, which facilitates the transformation of levodopa to dopa outside the central nervous system. 

Another example is to be found in the drug therapy of Parkinson s disease. The use of L-dopa (levodopa) as a prodrug for dopamine has already been described. However, to be effective, large doses of L-dopa (3-8 g per day) are required, and over a period of time these dose levels lead to side-effects such as nausea and vomiting. L-Dopa is susceptible to the enzyme dopa decarboxylase and as a result, much of the L-dopa administered is decarboxylated to L-dopamine before it reaches the central nervous system (Fig. 8.21). 

The classic example of this approach involves the use of levodopa (l-3,4-dihydroxyphenylalanine, Figure 8.13) to treat Parkinson s disease [58]. Parkinson s disease is distinguished by the marked depletion of dopamine— an essential neurotransmitter—in the basal ganglia. Direct dopamine replacement is not possible, because dopamine does not permeate through the blood-brain barrier. However, the metabolic precursor of dopamine, levodopa, is transported across brain capillaries by the neutral amino acid transporter (see Table 5.5 and the related discussion). Peripheral administration of levodopa, therefore, produces an increase in levodopa concentration within the central nervous system some of these molecules are converted into dopamine due to the presence of decarboxylate enzymes in the brain tissue, but decar-boxylate activity is also present in the intestines and blood. To prevent conversion of levodopa into dopamine before entry to the brain, levodopa is usually administered with decarboxylase inhibitors. 

Nervous system In a prospective 134-week double-blind study 747 patients with Parkinson s disease were randomized to co-careldopa with or without entacapone given qds at 3.5-hour intervals those who took entacapone had a shorter time to the onset of dyskinesia [93" ]. The authors suggested that the treatment protocol may not have made levodopa continuously available, although that was their original intention. 

Nervous system Severe hiccups have been attributed to levodopa [94 ]. 

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