What is the treatment for Parkinson's disease?

From the Guidelines

The treatment of Parkinson's disease involves a multifaceted approach aimed at managing symptoms and improving quality of life, with medication therapy typically beginning with levodopa (usually combined with carbidopa as Sinemet) at doses of 100/25 mg three times daily, as recommended by the most recent and highest quality study 1. The goal of treatment is to replace dopamine in the brain, and levodopa is the most effective drug in achieving this.

• Medication therapy should be individualized, with younger patients potentially starting with dopamine agonists like pramipexole (Mirapex) 0.125-1.5 mg three times daily or ropinirole (Requip) 0.25-4 mg three times daily to delay levodopa-related complications.
• MAO-B inhibitors such as selegiline (5-10 mg daily) or rasagiline (1 mg daily) can be added to enhance dopamine activity.
• As the disease progresses, COMT inhibitors like entacapone (200 mg with each levodopa dose) may help extend levodopa's effectiveness.
• In addition to medication, patients should be advised to take their levodopa-containing medications at least 30 min before meals to avoid interactions, and those experiencing motor fluctuations should try complying with a protein-redistribution dietary regimen to maximize levodopa absorption and efficacy, as recommended by the ESPEN guideline 1.
• Physical therapy, focusing on balance, flexibility, and strength exercises, is essential and should be performed daily.
• Deep brain stimulation surgery may be considered for patients with medication-resistant tremors or severe motor fluctuations, although the AASM suggests that clinicians not use deep brain stimulation for the treatment of secondary RBD due to medical condition in adults 1.
• Patients should maintain a regular sleep schedule, eat a balanced diet rich in fiber, and stay hydrated to manage constipation, a common side effect of medications.
• Regular monitoring by a neurologist is crucial as medication needs change over time due to disease progression and developing drug tolerance.

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. Selegiline's benefit in Parkinson's disease has only been documented as an adjunct to levodopa/carbidopa

The treatment for Parkinson's disease includes:

• Rasagiline (1 or 2 mg once daily) as initial monotherapy or adjunct therapy 2
• Pramipexole (0.375 mg to 4.5 mg/day) as monotherapy or adjunct therapy 3
• Selegiline as an adjunct to levodopa/carbidopa 4 Key points:
• These medications have been shown to be effective in improving symptoms of Parkinson's disease
• The dosage and administration of these medications may vary depending on the individual patient and the specific treatment regimen
• It is essential to consult the FDA drug label and clinical guidelines for the most up-to-date information on the treatment of Parkinson's disease 2, 3, 4

From the Research

Treatment Options for Parkinson's Disease

• The primary treatment for Parkinson's disease is symptomatic, focusing on improving motor and nonmotor signs and symptoms 5.
• Dopamine-based therapies, such as levodopa, are typically used to help initial motor symptoms 5, 6, 7, 8, 9.
• Nonmotor symptoms require nondopaminergic approaches, such as selective serotonin reuptake inhibitors for psychiatric symptoms and cholinesterase inhibitors for cognition 5.
• Rehabilitative therapy and exercise complement pharmacologic treatments 5, 8.

Pharmacologic Treatments

• Levodopa is the most efficacious pharmacological treatment for the symptoms of Parkinson's disease 6, 7, 8, 9.
• Dopamine agonists can be used alone before the introduction of levodopa or as an adjunct to levodopa 9.
• Addition of a peripherally-acting COMT inhibitor or an MAO-B inhibitor to levodopa can reduce motor fluctuations in patients with advanced disease 9.
• Amantadine may have mild symptomatic benefit and can decrease levodopa-induced dyskinesias 9.

Advanced Treatments

• Deep brain stimulation is an option for patients with levodopa-induced motor complications and relatively intact cognition 7, 9.
• Continuous dopaminergic drug delivery via apomorphine or Duodopa pumps can help individuals with medication-resistant tremor, worsening symptoms when the medication wears off, and dyskinesias 7.
• Subcutaneous apomorphine should be available for rescue use in patients with 'off' episodes 9.