Parkinson's disease: management
Parkinsons disease should only be diagnosed, and management initiated, by a
specialist with expertise in movement disorders. However, it is important for all
doctors to be aware of the medications used in Parkinson's given the prevalence of
this condition. NICE published guidelines in 2017 regarding the management of
Parkinson's disease.
For first-line treatment:
● if the motor symptoms are affecting the patient's quality of life: levodopa
● if the motor symptoms are not affecting the patient's quality of life: dopamine
agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO-B)
inhibitor
Whilst all drugs used to treat Parkinson's can cause a wide variety of side-effects
NICE produced tables to help with decision making:
Levodopa Dopamine agonists MAO-B inhibitors
Motor More improvement Less improvement Less improvement
symptoms in motor symptoms in motor symptoms in motor symptoms
Activities of More improvement Less improvement Less improvement
daily living in activities of daily in activities of daily in activities of daily
living living living
Motor More motor Fewer motor Fewer motor
complications complications complications complications
Adverse events Fewer specified More specified Fewer specified
adverse events* adverse events* adverse events*
* excessive sleepiness, hallucinations and impulse control disorders
If a patient continues to have symptoms despite optimal levodopa treatment or has
developed dyskinesia then NICE recommend the addition of a dopamine agonist,
MAO-B inhibitor or catechol-O-methyl transferase (COMT) inhibitor as an adjunct.
Again, NICE summarise the main points in terms of decision making:
, Dopamine MAO-B COMT Amantadine
agonists inhibitors inhibitors
Motor Improvement Improvement Improvement No evidence of
symptoms in motor in motor in motor improvement in
symptoms symptoms symptoms motor
symptoms
Activities of Improvement Improvement Improvement No evidence of
daily living in activities of in activities of in activities of improvement in
daily living daily living daily living activities of
daily living
Off time More off-time Off-time Off-time No studies
reduction reduction reduction reporting this
outcome
Adverse Intermediate Fewer adverse More adverse No studies
events risk of adverse events events reporting this
events outcome
Hallucination More risk of Lower risk of Lower risk of No studies
s hallucinations hallucinations hallucinations reporting this
outcome
Specific points regarding Parkinson's medication
NICE reminds us of the risk of acute akinesia or neuroleptic malignant syndrome if
medication is not taken/absorbed (for example due to gastroenteritis) and advise
against giving patients a 'drug holiday' for the same reason.
Impulse control disorders have become a significant issue in recent years. These
can occur with any dopaminergic therapy but are more common with:
● dopamine agonist therapy
● a history of previous impulsive behaviours
● a history of alcohol consumption and/or smoking
Parkinsons disease should only be diagnosed, and management initiated, by a
specialist with expertise in movement disorders. However, it is important for all
doctors to be aware of the medications used in Parkinson's given the prevalence of
this condition. NICE published guidelines in 2017 regarding the management of
Parkinson's disease.
For first-line treatment:
● if the motor symptoms are affecting the patient's quality of life: levodopa
● if the motor symptoms are not affecting the patient's quality of life: dopamine
agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO-B)
inhibitor
Whilst all drugs used to treat Parkinson's can cause a wide variety of side-effects
NICE produced tables to help with decision making:
Levodopa Dopamine agonists MAO-B inhibitors
Motor More improvement Less improvement Less improvement
symptoms in motor symptoms in motor symptoms in motor symptoms
Activities of More improvement Less improvement Less improvement
daily living in activities of daily in activities of daily in activities of daily
living living living
Motor More motor Fewer motor Fewer motor
complications complications complications complications
Adverse events Fewer specified More specified Fewer specified
adverse events* adverse events* adverse events*
* excessive sleepiness, hallucinations and impulse control disorders
If a patient continues to have symptoms despite optimal levodopa treatment or has
developed dyskinesia then NICE recommend the addition of a dopamine agonist,
MAO-B inhibitor or catechol-O-methyl transferase (COMT) inhibitor as an adjunct.
Again, NICE summarise the main points in terms of decision making:
, Dopamine MAO-B COMT Amantadine
agonists inhibitors inhibitors
Motor Improvement Improvement Improvement No evidence of
symptoms in motor in motor in motor improvement in
symptoms symptoms symptoms motor
symptoms
Activities of Improvement Improvement Improvement No evidence of
daily living in activities of in activities of in activities of improvement in
daily living daily living daily living activities of
daily living
Off time More off-time Off-time Off-time No studies
reduction reduction reduction reporting this
outcome
Adverse Intermediate Fewer adverse More adverse No studies
events risk of adverse events events reporting this
events outcome
Hallucination More risk of Lower risk of Lower risk of No studies
s hallucinations hallucinations hallucinations reporting this
outcome
Specific points regarding Parkinson's medication
NICE reminds us of the risk of acute akinesia or neuroleptic malignant syndrome if
medication is not taken/absorbed (for example due to gastroenteritis) and advise
against giving patients a 'drug holiday' for the same reason.
Impulse control disorders have become a significant issue in recent years. These
can occur with any dopaminergic therapy but are more common with:
● dopamine agonist therapy
● a history of previous impulsive behaviours
● a history of alcohol consumption and/or smoking
