From the Guidelines
The initial management of Parkinsonism should focus on a combination of pharmacological and non-pharmacological approaches tailored to the individual patient's symptoms and disease stage. For early Parkinsonism with minimal disability, treatment may begin with MAO-B inhibitors like selegiline (5-10 mg daily) or rasagiline (1 mg daily), which provide modest symptomatic benefit with fewer side effects than levodopa 1. When symptoms affect daily functioning, levodopa therapy (typically carbidopa-levodopa, starting at 25/100 mg three times daily) remains the gold standard due to its superior efficacy for motor symptoms. Dopamine agonists such as pramipexole (starting at 0.125 mg three times daily) or ropinirole (starting at 0.25 mg three times daily) may be considered as initial therapy, particularly in younger patients, to delay levodopa-related motor complications.
Key Considerations
- Non-pharmacological interventions should be implemented concurrently, including physical therapy to maintain mobility and balance, occupational therapy to address activities of daily living, and speech therapy for communication difficulties.
- Regular exercise programs should be encouraged as they improve motor function and quality of life 1.
- Patient education about the disease course, medication effects, and lifestyle modifications is essential.
- Monitoring of nutritional status is crucial, as patients with Parkinsonism are at increased risk of malnutrition and weight loss 1.
Disease-Specific Management
- For Parkinson's disease, the management approach should focus on addressing the dopamine deficiency underlying the condition while supporting overall function and quality of life.
- For other Parkinsonian syndromes, such as multiple system atrophy (MSA), progressive supranuclear palsy (PSP), and corticobasal degeneration (CBD), the management approach may need to be tailored to the specific symptoms and disease characteristics 1.
Ongoing Care
- Regular follow-up appointments are necessary to monitor disease progression, adjust treatment plans as needed, and address any emerging symptoms or concerns.
- A multidisciplinary approach to care, involving healthcare professionals from various specialties, can help ensure comprehensive management of Parkinsonism and its related complications.
From the FDA Drug Label
The primary outcome measure in this trial was the proportion of patients experiencing a decrease (compared with baseline) of at least 30% in the UPDRS motor score. Patients were titrated for up to 10 weeks, starting at 0.5 mg twice daily, with weekly increments of 0.5 mg twice daily to a maximum of 5 mg twice daily.
The initial management approach for a patient with Parkinsonism may involve the use of dopamine agonists such as ropinirole or pramipexole.
- The starting dose of ropinirole is 0.5 mg twice daily, with weekly increments of 0.5 mg twice daily to a maximum of 5 mg twice daily.
- The starting dose of pramipexole is 0.375 mg/day and is titrated to a maximally tolerated dose, but no higher than 4.5 mg/day in three divided doses. The goal of treatment is to improve motor function and reduce "off" time, as measured by the Unified Parkinson's Disease Rating Scale (UPDRS) 2 3.
From the Research
Initial Management Approach for Parkinsonism
The initial management approach for a patient with Parkinsonism involves a comprehensive assessment and individualized treatment plan.
- The diagnosis of Parkinson disease is based on history and examination, including prodromal features, characteristic movement difficulty, and psychological or cognitive problems 4.
- Treatment is symptomatic, focused on improvement in motor and nonmotor signs and symptoms, with no disease-modifying pharmacologic treatments available 4.
Pharmacologic Treatments
Pharmacologic treatments for Parkinsonism typically involve:
- Dopamine-based therapies, such as carbidopa-levodopa, to help initial motor symptoms 4, 5, 6, 7.
- Nonmotor symptoms require nondopaminergic approaches, such as selective serotonin reuptake inhibitors for psychiatric symptoms and cholinesterase inhibitors for cognition 4.
- Dopamine agonists, MAO-B inhibitors, and COMT inhibitors can be used as adjunctive therapies to reduce motor fluctuations and improve symptoms 5, 6, 7.
Nonpharmacologic Approaches
Nonpharmacologic approaches, such as:
- Rehabilitative therapy and exercise, can complement pharmacologic treatments and improve motor and nonmotor symptoms 4, 6.
- Deep brain stimulation can be an option for patients with levodopa-induced motor complications and relatively intact cognition 7.
Treatment Strategies
Treatment strategies for Parkinsonism may vary depending on the patient's age, symptoms, and response to treatment.