From the Guidelines
The initial treatment for patients presenting with Parkinsonism should focus on addressing the underlying cause, and if symptoms are induced by antidopaminergic agents, anticholinergic or mild dopaminergic agents such as amantadine may be used to treat these symptoms. When considering treatment options, it's crucial to differentiate between Parkinson's disease side effects and symptoms of the underlying illness, such as negative symptoms or catatonia, as noted in the practice parameter for the assessment and treatment of children and adolescents with schizophrenia by the American Academy of Child and Adolescent Psychiatry 1. Key considerations in managing Parkinsonism include:
- Identifying and potentially adjusting or discontinuing the offending antidopaminergic agent if possible
- Using anticholinergic agents or amantadine to alleviate symptoms such as bradykinesia, tremors, and rigidity
- Carefully monitoring patients for the emergence of side effects from these treatments and adjusting the therapeutic plan as necessary
- Recognizing the challenges in differentiating between drug-induced Parkinsonism and symptoms of the underlying psychiatric condition, which may require consultation with specialists in psychiatry and neurology. Given the potential complexity of managing Parkinsonism, especially when it arises as a side effect of psychiatric treatment, a tailored approach that considers the individual patient's condition, the severity of Parkinsonian symptoms, and the psychiatric diagnosis is essential.
From the FDA Drug Label
The effectiveness of pramipexole dihydrochloride tablets in the treatment of Parkinson's disease was evaluated in a multinational drug development program consisting of seven randomized, controlled trials Three were conducted in patients with early Parkinson's disease who were not receiving concomitant levodopa, and four were conducted in patients with advanced Parkinson's disease who were receiving concomitant levodopa The primary measure of effectiveness was the change from baseline in the total score of the Unified Parkinson’s Disease Rating Scale (UPDRS) 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 initial treatment for patients presenting with Parkinsonism may include pramipexole or rasagiline, as both have shown effectiveness in improving symptoms of Parkinson's disease.
- Pramipexole has been evaluated in seven randomized, controlled trials, with three conducted in patients with early Parkinson's disease and four in patients with advanced Parkinson's disease.
- Rasagiline has been established as effective in four 18-to 26-week, randomized, placebo-controlled trials, as initial monotherapy or adjunct therapy. Key points to consider when choosing an initial treatment include:
- The patient's disease duration and severity
- The presence of any concomitant medications, such as levodopa or dopamine agonists
- The patient's response to treatment, as measured by the Unified Parkinson's Disease Rating Scale (UPDRS) 2 3
From the Research
Initial Treatment for Parkinsonism
The initial treatment for patients presenting with Parkinsonism depends on various factors, including the patient's age, symptoms, and overall health.
- For patients under 65 years old, or above 65 years old but with preserved mental function and no severe comorbidity, initial monotherapy with a dopamine agonist is advisable 4.
- Dopamine agonists, such as pramipexole and ropinirole, provide sustained dopaminergic stimulation and can delay the initiation of levodopa treatment and reduce the frequency of motor complications 5, 6.
- Levodopa is the most effective drug in the symptomatic treatment of Parkinson's disease, but it is often used in combination with dopamine agonists to minimize motor complications 5, 4.
- The choice of initial treatment also depends on the patient's symptoms, with levodopa being preferable for severe akinesia, anticholinergics for tremor-dominant Parkinson's disease, and dopamine agonists for younger patients with mild symptoms 4, 7.
Considerations for Initial Treatment
When initiating treatment for Parkinson's disease, it is essential to consider the patient's individual needs and circumstances.
- Patient education and counseling are crucial in helping patients understand their condition and treatment options 7.
- The decision to initiate treatment should be based on the patient's level of disability and functional impairment, rather than their age or disease severity alone 8, 7.
- Non-motor symptoms, such as anxiety and depression, should also be managed as part of the initial treatment plan 7.
Treatment Options
Various treatment options are available for Parkinson's disease, including: