What is the recommended treatment for Parkinson's disease?

From the Guidelines

The recommended treatment for Parkinson's disease typically involves medication therapy, with levodopa being the gold standard, and should be taken at least 30 min before meals to maximize absorption and efficacy. Treatment usually begins with either levodopa (combined with carbidopa to prevent side effects) or dopamine agonists like pramipexole, ropinirole, or rotigotine 1. For early or mild Parkinson's, MAO-B inhibitors such as selegiline or rasagiline may be used. As the disease progresses, combinations of these medications are often necessary, with levodopa doses typically starting at 100mg three times daily and increasing as needed. Some key points to consider in the treatment of Parkinson's disease include:

• Advising patients to take levodopa medications at least 30 min before meals to avoid interactions with dietary large neutral amino acids 1
• Recommending a protein-redistribution dietary regimen to maximize levodopa absorption and efficacy in patients experiencing motor fluctuations 1
• Considering deep brain stimulation surgery for patients with advanced disease who respond to levodopa but have motor fluctuations or dyskinesias
• Incorporating regular physical therapy, occupational therapy, and speech therapy into the treatment plan
• Individualizing treatment based on the patient's age, symptom severity, cognitive status, and other medical conditions 1. Additionally, patients should undergo active monitoring of vitamin status, as low vitamin D levels have been associated with the risk of developing Parkinson's disease, and supplementation may be necessary 1. Exercise has been shown to improve mobility and quality of life, and should be encouraged as part of the treatment plan.

From the FDA Drug Label

The effectiveness of rasagiline tablets for the treatment of Parkinson’s disease was established in four 18-to 26-week, randomized, placebo-controlled trials, as initial monotherapy or adjunct therapy. Rasagiline tablets (1 or 2 mg once daily) were superior to placebo on the primary measure of effectiveness in patients receiving six months of treatment and not on dopaminergic therapy. One of the two early Parkinson's disease studies (N=335) was a double-blind, placebo-controlled, parallel trial consisting of a 7 week dose escalation period and a 6 month maintenance period. Patients treated with pramipexole dihydrochloride tablets had a starting daily dose of 0.375 mg and were titrated to a maximally tolerated dose, but no higher than 4.5 mg/day in three divided doses.

The recommended treatment for Parkinson's disease includes:

• Rasagiline tablets, 1 or 2 mg once daily, as initial monotherapy or adjunct therapy 2
• Pramipexole dihydrochloride tablets, with a starting daily dose of 0.375 mg and titrated to a maximally tolerated dose, but no higher than 4.5 mg/day in three divided doses 3 Key points:
• Rasagiline and pramipexole have been shown to be effective in the treatment of Parkinson's disease
• The effectiveness of these medications was established in randomized, placebo-controlled trials
• The recommended dosage and administration of these medications vary depending on the specific medication and the individual patient's needs.

From the Research

Treatment Options for Parkinson's Disease

The recommended treatment for Parkinson's disease (PD) typically involves a combination of medications and therapies. Some of the key treatment options include:

• Levodopa, a dopamine precursor, which is an effective and well-tolerated dopamine replacement agent used to treat PD 4, 5
• Dopamine agonists, which can be used alone or as an adjunct to levodopa 4, 6
• Monoamine oxidase B (MAOB) inhibitors, which can be used to reduce motor fluctuations in patients with advanced disease 7, 6
• Catechol-O-methyltransferase (COMT) inhibitors, such as entacapone, which can be used to improve the bioavailability of levodopa 4, 5
• Deep brain stimulation, which is an option for patients with levodopa-induced motor complications and relatively intact cognition 8, 6

Medication Management

Medication management is a crucial aspect of PD treatment. The goal is to find the right combination and dosage of medications to control symptoms and minimize side effects. Some key considerations include:

• Levodopa is the most potent dopaminergic therapy for PD, but its chronic use can lead to motor complications such as response fluctuations, dyskinesia, and psychiatric problems 4, 5
• The use of a dopa-decarboxylase inhibitor (DDCI) such as carbidopa can help reduce the peripheral conversion of levodopa to dopamine and increase its bioavailability 4, 5
• The addition of a COMT inhibitor such as entacapone can further extend the half-life of levodopa and increase its bioavailability 4, 5

Advanced Treatment Options

For patients with advanced PD, there are several advanced treatment options available, including:

• Levodopa-carbidopa enteral suspension, which can help control motor fluctuations and dyskinesias 8
• Deep brain stimulation, which can help control levodopa-induced motor complications and improve quality of life 8, 6
• Device-aided therapies such as duodenal infusion of a levodopa/carbidopa gel, transdermal levodopa patch, and oral pro-levodopa 4, 7