What is the initial treatment and management approach for a patient suspected of having Parkinson's disease?

From the Guidelines

The initial treatment and management of suspected Parkinson's disease begins with a comprehensive neurological evaluation to confirm the diagnosis, as there is no definitive test for the condition. Once Parkinson's disease is suspected, levodopa (typically combined with carbidopa as Sinemet) remains the gold standard medication, usually starting at a low dose such as 25/100 mg three times daily and gradually titrating based on symptom response 1. For younger patients (under 65) or those with milder symptoms, dopamine agonists like pramipexole (0.125-0.5 mg three times daily) or ropinirole (0.25-1 mg three times daily) may be considered first to delay levodopa-related motor complications. MAO-B inhibitors such as rasagiline (1 mg daily) or selegiline (5 mg twice daily) offer another option for early treatment with fewer side effects. Beyond medication, management should include:

• Regular exercise
• Physical therapy focused on balance and mobility
• Occupational therapy for daily activities
• Speech therapy if speech is affected. Patient education about the progressive nature of the disease and potential medication side effects is essential, and patients should be advised to take their levodopa-containing medications about 30 min before meals to avoid interactions 1. Additionally, patients experiencing motor fluctuations should be recommended to comply with controlled-protein dietary regimens to maximize levodopa absorption and efficacy 1. Regular follow-up appointments every 3-6 months allow for medication adjustments as the disease progresses. This multifaceted approach addresses both motor symptoms through medication and functional limitations through supportive therapies, improving quality of life while managing disease progression. It is also important to monitor body weight and vitamin status, as weight loss and malnutrition have been associated with disease severity, and low vitamin D levels have been associated with the risk of developing PD 1. Supplementation of vitamin D and B12 should be considered to slow disease progression and prevent complications associated with hyper-homocysteinemia 1.

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. The primary measure of effectiveness was the change from baseline in the total score of the Unified Parkinson’s Disease Rating Scale (UPDRS), [mentation (Part I) + activities of daily living (ADL) (Part II) + motor function (Part III)]

The initial treatment and management approach for a patient suspected of having Parkinson's disease may include monotherapy with rasagiline tablets 1 mg/day or 2 mg/day, as it has been shown to be effective in improving UPDRS scores 2.

• Key points:
  • Rasagiline tablets can be used as initial monotherapy.
  • The effective dose is 1 mg/day or 2 mg/day.
  • UPDRS scores are used to measure the effectiveness of the treatment.
• Important consideration: The effectiveness of rasagiline tablets has been established in patients not receiving any concomitant dopaminergic therapy at the start of the study.

From the Research

Initial Treatment and Management Approach for Parkinson's Disease

The initial treatment and management approach for a patient suspected of having Parkinson's disease involves a combination of pharmacologic and nonpharmacologic approaches.

• The diagnosis of Parkinson's disease is based on history and examination, including prodromal features, characteristic movement difficulty, and psychological or cognitive problems 3.
• Dopamine-based therapies, such as levodopa preparations, are typically used to help initial motor symptoms, while nonmotor symptoms require nondopaminergic approaches, such as selective serotonin reuptake inhibitors for psychiatric symptoms and cholinesterase inhibitors for cognition 3.
• Rehabilitative therapy and exercise can complement pharmacologic treatments and help improve motor and nonmotor signs and symptoms 3.

Pharmacologic Treatment Options

Several pharmacologic treatment options are available for Parkinson's disease, including:

• Levodopa preparations, which are the most efficacious dopamine substituting drugs 4
• Dopamine agonists, such as pramipexole, ropinirole, and rotigotine, which can be effective as monotherapy or in combination with levodopa 5, 6
• Monoamine oxidase type-B (MAO-B) inhibitors, such as selegiline and rasagiline, which can be effective in combination with levodopa 6
• Catechol-O-methyltransferase (COMT) inhibitors, such as entacapone and tolcapone, which can be used in combination with levodopa and carbidopa 7

Nonpharmacologic Treatment Options

Nonpharmacologic treatment options, such as rehabilitative therapy and exercise, can also be effective in managing Parkinson's disease.

• These approaches can help improve motor and nonmotor signs and symptoms, and can be used in combination with pharmacologic treatments 3.
• Advanced treatments, such as deep brain stimulation and therapy with levodopa-carbidopa enteral suspension, can also be effective in managing complications, such as worsening symptoms and functional impairment when a medication dose wears off ("off periods"), medication-resistant tremor, and dyskinesias 3.