From the Guidelines
The treatment of Parkinson's disease should prioritize a combination of medications and supportive therapies tailored to each patient's symptoms, with levodopa as the cornerstone of pharmacological treatment, and consideration of protein redistribution dietary regimens to maximize levodopa absorption and efficacy. The goal of treatment is to maintain quality of life while minimizing medication side effects and managing morbidity and mortality. According to the most recent and highest quality study 1, patients experiencing motor fluctuations should try complying with a protein-redistribution dietary regimen, which involves taking levodopa medications at least 30 min before meals and redistributing protein intake throughout the day.
Key Components of Treatment
- Medications:
- Levodopa, usually combined with carbidopa (Sinemet) to prevent peripheral conversion and reduce side effects, with initial dosing often starting at 25/100 mg three times daily, gradually increasing as needed 1
- Dopamine agonists like pramipexole (0.125-1.5 mg three times daily) or ropinirole (0.25-4 mg three times daily) for early-stage Parkinson's, especially in younger patients, to delay levodopa-related motor complications
- MAO-B inhibitors such as selegiline (5 mg twice daily) or rasagiline (1 mg daily) as monotherapy in early disease or as adjuncts to levodopa
- COMT inhibitors like entacapone (200 mg with each levodopa dose) to extend levodopa's effect by preventing its breakdown
- Supportive therapies:
- Physical therapy
- Occupational therapy
- Speech therapy
- Dietary considerations:
- Protein redistribution dietary regimens to maximize levodopa absorption and efficacy, with a daily protein intake of 0.8-1.0 g/kg of body weight 1
Advanced Disease Management
For advanced disease with motor fluctuations, extended-release formulations, continuous infusion therapies (like levodopa-carbidopa intestinal gel), or deep brain stimulation may be considered 1. The treatment regimen should be regularly adjusted based on symptom progression, with the goal of maintaining quality of life while minimizing medication side effects. Optimization of antiparkinsonian treatment is also crucial to ameliorate motor symptoms that contribute to dysphagia in PD patients 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. Study 2 was a double-blind, randomized, placebo-controlled, parallel group, 18-week study, investigating rasagiline tablets 1 mg as adjunct therapy to dopamine agonists without levodopa. In Study 2, rasagiline tablets 1 mg was superior to placebo on the primary measure of effectiveness. Study 3 and Study 4 were randomized, multinational trials conducted in more advanced Parkinson's disease patients treated chronically with levodopa and experiencing motor fluctuations. 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. At the end of the 6 month maintenance period, the mean improvement from baseline on the UPDRS part II total score was 1.9 in the group receiving pramipexole dihydrochloride tablets and -0.4 in the placebo group. The mean improvement from baseline on the UPDRS part III total score was 5.0 in the group receiving pramipexole dihydrochloride tablets and -0.8 in the placebo group.
The treatment protocol for Parkinson's disease may include:
- Rasagiline tablets 1 or 2 mg once daily as initial monotherapy or adjunct therapy
- 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
- Levodopa with or without decaborylase inhibitor, with a mean dose of approximately 700 to 800 mg/day
- Dopamine agonists, such as ropinirole or pramipexole, with or without levodopa
- Entacapone with levodopa/decarboxylase inhibitor in some patients 2
- Selegiline, anticholinergics, or amantadine may also be used in combination with other treatments 3
From the Research
Treatment Protocol for Parkinson's Disease
The treatment protocol for Parkinson's disease is primarily symptomatic, focusing on improving motor and nonmotor signs and symptoms. The following are key aspects of the treatment protocol:
- Pharmacologic treatments: Dopamine-based therapies, such as levodopa and dopamine agonists, are typically used to help initial motor symptoms 4, 5, 6, 7, 8.
- Nonpharmacologic approaches: Rehabilitative therapy, exercise, and physical, occupational, and speech therapies complement pharmacologic treatments 4, 6.
- Advanced treatments: Advanced treatments, such as deep brain stimulation and levodopa-carbidopa enteral suspension, can help individuals with medication-resistant tremor, worsening symptoms, and dyskinesias 4, 6, 8.
- Palliative care: Palliative care is part of Parkinson's disease management, focusing on improving the quality of life for patients and their families 4.
Treatment Options
The following are treatment options for Parkinson's disease:
- Levodopa: Levodopa is still the gold standard for treating Parkinson's disease, and it can be used in combination with other medications 5, 7, 8.
- Dopamine agonists: Dopamine agonists can be used alone or in combination with levodopa to help manage motor symptoms 5, 6, 7, 8.
- Anticholinergics: Anticholinergics can be used to improve symptoms such as tremor and rigidity, but their use is limited by their side effects 5, 7, 8.
- Amantadine: Amantadine may be a useful drug for initial treatment of Parkinson's disease, particularly for patients with mild symptoms 5, 7, 8.
- MAO-B inhibitors: MAO-B inhibitors, such as selegiline, may have a neuroprotective effect and can be used as an adjunct to levodopa therapy 6, 7.
- COMT inhibitors: COMT inhibitors can be used to reduce motor fluctuations in patients with advanced disease 6, 8.
Individualized Treatment
Treatment for Parkinson's disease should be individualized, taking into account the patient's age, disability, and tolerance to medications 5, 6, 7, 8. The treatment protocol may need to be adjusted over time as the disease progresses and the patient's needs change.