A. Peak dose chorea

1. Evaluate the value of adjunctive PD medications

2. Decrease risk by lowering Sinemet dose when adding other PD medications

3. Adjust levodopa formulation, dose, or frequency

4. Add amantadine

5. Add propranolol, fluoxetine, buspirone, or clozapine

6. Deep-brain stimulation

B. Off period dystonia in the early morning (e.g., foot cramping)

1. Add Sinemet CR or dopamine agonist at bedtime if having nighttime offs

2. Morning Sinemet dose should be immediate-release with or without CR

3. Selective denervation with botulinum toxin

4. Add lithium or baclofen C. Diphasic dyskinesia

1. Avoid controlled-release preparations; consider liquid Sinemet

2. Add dopamine agonist, amantadine, or COMT inhibitor

3. Increase Sinemet dose and frequency

4. Deep brain stimulation III. Akathisia

1. Benzodiazepine

2. Propranolol

3. Dopamine agonists

4. Gabapentin

COMT, catechol-O-methyltransferase. From Refs. 2, 15, 16, 44-46.

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