From the Research
Acute psychosis in Parkinson's disease should be treated with pimavanserin (Nuplazid) 34mg daily as first-line therapy, as it effectively manages hallucinations and delusions without worsening motor symptoms. This recommendation is based on the most recent and highest quality study available, which suggests that pimavanserin is the first-line choice for mild symptoms 1.
Treatment Approach
When treating acute psychosis in Parkinson's disease, it's essential to first eliminate potential triggers by discontinuing anticholinergics, amantadine, dopamine agonists, and MAO-B inhibitors, while maintaining levodopa at the lowest effective dose 2. Underlying causes such as infections, metabolic disturbances, or medication interactions should be identified and treated.
Alternative Treatment Options
If pimavanserin is unavailable or ineffective, quetiapine can be used starting at 12.5-25mg at bedtime and gradually titrated up to 100-200mg daily as needed 3. Clozapine is also effective at low doses (6.25-50mg daily) but requires regular blood monitoring due to the risk of agranulocytosis 4, 5.
Non-Pharmacological Approaches
Non-pharmacological approaches, including maintaining a consistent environment, providing reassurance, and educating caregivers, are important adjuncts to medication 1. Hospitalization may be necessary for severe psychosis with agitation.
Treatment Duration
Treatment typically continues for at least 3-6 months before attempting a gradual taper, as premature discontinuation often leads to symptom recurrence 2. It's crucial to prioritize the patient's quality of life, morbidity, and mortality when making treatment decisions, and to choose the treatment option that best balances efficacy with safety and tolerability 1.