The Poisonus Medicine

A month ago, a 65-year-old Chinese lady came to my clinic due to the deterioration of her physical condition. She had been diagnosed to have Parkinson's Disease (PD) for about seven years. Two weeks before she met me, she was almost permanently wheelchair-ridden.

The diagnosis of PD in this patient was not an issue at all as she had all the typical features of the illness. As her son pushed her wheelchair into my clinic, her hands were trembling a lot. Her body was very stiff, to the extent that she could not even stand up with my help. Even right from the beginning I knew that something was not right about this lady - nowadays Parkinson's patient generally do not end up getting wheelchair-ridden.

I was surprised when I discovered that she was taking only Madopar (250) half tablet a day and Selegiline (5 mg) half tablet a day. This daily dosage of medications was way too low for any Parkinson's patient who has been suffering from this illness for seven years. On average, by the seventh year of illness, most patients require about three tablets of Madopar (250) per day, in addition to several other types of medications.

I advised her to gradually increase the dose of Madopar from half tablet three times a day, up to one tablet three times a day, over a period of three weeks. I explained to her and the children that as the dose of Madopar was increased, the patient's condition usually would get better and better. I also managed to convince the patient that she would be able to walk at home unassisted, without much tremor when she took three tablets of Madopar per day.

And she really did improve with half tablet of Madopar, being able to walk slowly using a stick. Her tremor also significantly reduced at this stage. However, when the dose of Madopar was increased to three-quarter tablet, she trembled even more. By the time she took one tablet of Madopar, her tremor got even worse and she was back to the wheelchair again. Obviously disturbed by the unexpected development, her children brought her back to me.

There are several reasons why some Parkinson's patients fail to respond positively to treatment. Firstly, it could be wrong diagnosis. However, I did not think this was the case in this patient because I was very convinced of her diagnosis of PD. Secondly, it could be due to side effects of medication such as nausea, vomiting and dizziness (some Parkinson's medications can cause reduction in blood pressure). But this lady denied having such symptoms. Her blood pressure was also normal for her age.

The third possibility is co-existing anxiety disorder, which is very common among Parkinson's patients. Generally I have found Parkinson's patients to be rather sensitive people. They have difficulty adapting to environmental changes (people staring at them, people's remarks or comments) and also to the Parkinson's medications. One of the manifestations of anxiety disorder is unnecessary (and unjustified) worry about the side effects of medications.

This lady's "lack of response" to medications was caused by co-existing anxiety disorder. It is well-known that any form of anxiety (anger, embarrassment) itself can worsen the symptoms of PD, and even lead to freezing (the "jamming" of body movement). While the dose of Madopar was increased, she also experienced other symptoms of anxiety disorder such as "feeling of faintness", weakness, palpitation and difficulty in breathing (which are not the typical side effects of medications). In other words, she did not have any side effects of medications - it was all in her mind.

"I have always tried my best not to take any Western medicine because it may cause long term silent damage to my body system. Taking half tablet of Madopar is alright. But I think one tablet of Madopar is too "strong' and may cause a lot of damage to my body," she said.

Her son added, "my mother has always been an anxious person - she worried about everything. She would consult the sinseh (the traditional Chinese medicine man) for any sickness. In fact, she has taken herbal medicine regularly for her Parkinson's. She has always considered Western medicine to be poisonous." 

Her reluctance in taking Western medicine explained why she had tried to minimize the daily dose of Madopar, despite knowing that this would slow her down. I was amazed that she was willing to be physically impaired and have a rather poor quality of life than to increase the dose of Madopar.

For many Malaysian Chinese, especially the elderly people, traditional Chinese medicine such as herbal treatment and acupuncture has always been regarded as safe, natural treatment. Western medicine, especially pills given orally, is perceived as strong, artificial medicine which has biochemical substance that can potentially cause "side effects" to the internal organ.

Even my own mother had always been a strong believer in traditional Chinese medicine. I fondly remember my mother "treating" my various illnesses when I was very young. When I had fever, she gave me a Chinese herbal medicine called leong sam sou (the roots of one kind of plant) instead of bringing me to a doctor. When I had dislocation of my shoulder joint (a condition in which the bones of the shoulder joint are no longer in the normal position) due to a fall, she sought the help of an uncle who was a so-called "expert" in massaging. I can still recall how he applied some herbal leaves on my shoulder before massaging my shoulder joint. The day after, I was my usual self again, running and playing with my childhood friends without any shoulder pain anymore.

As such, I advised the patient to reduce the dose of Madopar to half tablet three times a day. At this lower dosage, she felt much better with minimal anxiety symptoms. As expected, she was still slow but managed to walk around the house without needing assistance. Even though she is not in the best physical condition at present, I feel that it is the best decision in view of her firm cultural belief. After some time, I will try again to increase the dose of her medication again - she probably needs a break.

Interestingly, a new medication for PD which is available as skin patch (Rotigotine / Neupro) will be arriving in Malaysia next year. Skin patch is a well established traditional Chinese treatment method that is used to treat various medical illnesses such as muscle pain and backache. It will be exciting to know whether skin patch (Rotigotine) for PD will be more easily accepted by the Chinese Parkinson's patients than the oral tablets. It this is true, the skin patch (Rotigotine) may have its advantage over the oral tablets.

In summary, anxiety disorder should be recognized as a common problem among Parkinson's patients, which can result in "treatment failure". The way to tackle this "treatment failure" is to increase the dose of medication in a much more gradual manner, after giving appropriate explanation and assurance to the patients (that the Parkinson's medication is not a "poison").

Cultural perception, an important factor that determines treatment response, should be given proper attention in the treatment of PD in a multi-racial country such as Malaysia. Parkinson's patients who believe in traditional Chinese medicine should be allowed to do so, as long as they continue to take the Western medicine. What I always tell them is that a combination of traditional Chinese medicine and Western medicine probably works better than either one.