Brief Answer:
Next step is probably a sleep study and pulmonary function testing

Detailed Answer:
......would probably be a SLEEP STUDY as well as Pulmonary Function Testing (PFT's).

In my patients I would also consider substituting tramadol for another form of pain relief. As a neurologist I'm not crazy about that drug for a number of reasons but in your husband's case with Parkinson's that drug can increase his risk of falls, reduce clarity of thinking, and interact with other drugs he may be taking. For example, he is citalopram.....there is a slight risk associated with Tramadol and Citalopram causing something rather nasty called SEROTONIN SYNDROME. In someone with Parkinson's Disease that could spell absolute disaster. Are you even sure that your husband NEEDS an antidepressant? Lots of doctors and caregivers mistake the MASKED FACIAL EXPRESSION, the LOW VOLUME SPEECH, and THE SLOW MOVEMENTS of PARKINSON's patients as a sign of depression.....In my PD patients a very small percentage of them are truly depressed by clinical criteria outlined by the DSM V.

In other words, I would recommend looking into taking out as much medication as possible that is either clearly not working or doing anything for him and only live medication behind that you KNOW is of some measurable benefit.

You'll have to specify the breathing problems a bit more but can you get him some Pulmonary Function Studies? Let's make sure he's not having breathing muscle weakness because there are some things that should be looked at right away if that's the case. The sleep study would be useful to rule out SLEEP APNEA and sleep disturbances that could be related to his PD.

Also, when's the last time your husband had his thyroid functions checked? I would go for a FULL BATTERY OF THYROID TESTS given his relatively unusual breathing difficulties. That would be an FT4, TSH, T3, T4, FT3. Then, what about a cardiac workup to make sure that the trouble breathing isn't because some congestive problems of the heart?

Finally, I want you to optimize his Madopar medication by observing the following rules....very simple to remember really....but you won't believe how much of a difference it can make in him within a few days of implementing this plan:

1. Be sure that he doesn't miss his doses of his MADOPAR by more than 15-30 min. per the routine schedule. If he does not get his medication in on time he will deteriorate and nobody will think in terms of the dosing schedule of his medicine.

2. Make sure that he does not take his medications any closer to meal times than 1-2 hrs.

3. Make sure the protein content of his meals is less than 30%. That is because if his meals and what he takes to his stomach goes over 30% protein content then, it will compete and block the MADOPAR from entering the gut and reduce then, the bioavailability of the medication making it appear as if his PD is doing worse....or at least not getting any better. The comtan will also not have much to work with and therefore, could become a useless and even complicating medicine to take.

I hope these answers satisfactorily address your questions. If so, may I ask the favor of a HIGH STAR RATING with some written feedback?

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Brief Answer:
Breathing difficulties

Detailed Answer:
Good morning from some 3/4 the way around the globe (to the East that is!). I've read your followup comment and will comment that gabapentin can be a somewhat unpredictable player as patients go. As an example, my brother took 100mg one time for some back pain he was having....he's 5 years my junior, a physician as well, very active physically as well with his patients (thin as a rake I might add), and he must've slept for 2 days after taking what most of us who prescribe that medication an insignificant dose. Manufacturer's recommendation for most people's needs range from 300-900 mg./daily. On the other end of the spectrum I have a patient who has Multiple Sclerosis, has been disabled for the better part of 15 years since I've known her and entirely enjoys and MUST HAVE no less than 7200mg. daily in order to function! Every time I refill the prescription I have to fight with the pharmacy because they simply can't believe that a human being can tolerate that dosage. But it's absolutely true. My point being that people are as different in their reactions to medications as there are different shaped pebbles on the XXXXXXX beaches of New Zealand...would love to know the island someday for all its beauty and history that I've read. But that's how gabapentin operates in folks. I can appreciate why the neurologist wanted to replace the tramadol with the gabapentin because in general neurologists have a tendency not to prefer Tramadol for its other side effect profile in our patients which is that of seizures. Were you aware of that little potential complication of the drug? If not, then, you and your husband need to understand that Tramadol can IN SOME people lower the brain's seizure threshold and cause convulsions. It happens in about 2-5% of patients exposed to the drug. Not only that but as a pain reliever it is a synthetic opiate and therefore, has the property of causing dependency (both psychological as well as physical). Doses have to be escalated as time goes on to maintain the same degree of painkilling relief and if the medication is stopped it can cause withdrawal types of effects.

Therefore, I can fully appreciate the rationale behind the neurologist's move. Furthermore, upon switching those drugs out I don't know if some of your husband's symptoms couldn't've been due to exactly what I just mentioned giving some of your reported symptoms of perspiration and difficulty with breathing...that can happen as part of a withdrawal syndrome. Notwithstanding, I understand your concern over the use of gabapentin as far as having "knocked" either him out. Gabapentin doesn't really interact chemically to any extent to the other medications in his regimen so I wouldn't necessarily want to say that it knocked out his Madopar or Comtan....that wouldn't be an accurate statement. But it certainly could've knocked HIM OUT as gabapentin did to my brother and to many other patients I've treated over the years. So that much I'm with you on.

Now, as far as the breathing difficulties are concerned. You say that his chest has been checked out and X-rays don't show much. And those are good things. And it is also good to mention to his doctor the idea of doing thyroid studies especially if they've not been done in awhile. Not only that but as I mentioned in my other note people with Parkinson's Disease show a high concordance rate with the disease entity known as SLEEP APNEA and should be checked at least once with a sleep study to see whether or not he could benefit from the use of a breathing machine at home. Sleep apnea if not diagnosed can damage the heart (and the brain) which obviously can make breathing, walking, and functioning all the more difficult not to mention the possibility of making his Parkinson's worse if in fact, we are dealing with damage to those areas of the brain responsible for making his dopamine.

As well, if he were my patient I would likely put him under a cardiology consult so they check his baseline heart parameters such as ejection fraction, cardiac muscle strength and efficiency, as well as the detection of any evidence of congestive heart failure which often can start insidiously as mild breathing difficulties, especially upon exertion....later comes the swelling in the extremities, and even later would be pulmonary changes that could be appreciated on X-rays..but that's a very late stage of the disease. A chest x-ray is not useful in seeing or predicting the presence of very mild or early stage disease. For that we need the echocardiogram, EKG, and even treadmill stress test if appropriate for him though I don't know with his Parkinson's whether or not he could tolerate that activity.

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