What is the medical management for Parkinson’s disease?

From the Guidelines

Medical management for Parkinson's disease focuses on symptom control through medication, as there is currently no cure, with levodopa remaining the most effective medication for controlling motor symptoms 1. The primary goal of treatment is to alleviate symptoms and improve quality of life.

• Treatment typically begins with levodopa (usually combined with carbidopa as Sinemet), with starting doses often 25/100 mg three times daily, gradually increasing as needed.
• For younger patients or those with milder symptoms, physicians may initially prescribe 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 mg twice daily) or rasagiline (1 mg daily) may be used as early monotherapy or as adjuncts.
• COMT inhibitors like entacapone (200 mg with each levodopa dose) extend levodopa's effectiveness, and optimization of antiparkinsonian treatment is advised to ameliorate motor symptoms that contribute to dysphagia in PD patients 1. As the disease progresses, medication regimens become more complex, often requiring combinations of these drugs with careful timing to manage "wearing-off" effects and dyskinesias.
• Non-motor symptoms may require additional medications such as antidepressants, anticholinergics for urinary symptoms, or medications for cognitive issues. Regular follow-up with a neurologist is essential to adjust medications as the disease evolves, balancing symptom control against side effects, and to monitor for potential complications such as weight changes, vitamin deficiencies, and metabolic disorders 1. Regular monitoring of body weight and nutritional assessment are recommended, at least on a yearly basis, to prevent malnutrition and metabolic complications 1. Additionally, supplementation with vitamin D should be considered, as low levels have been associated with disease progression, and administration of folate and vitamin B12 may be effective in reducing homocysteine levels and preventing neuropathy 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY Mechanism of Action Parkinson's disease is a progressive, neurodegenerative disorder of the extrapyramidal nervous system affecting the mobility and control of the skeletal muscular system. Its characteristic features include resting tremor, rigidity, and bradykinetic movements. Symptomatic treatments, such as levodopa therapies, may permit the patient better mobility Rationale for the Use of a Selective Monoamine Oxidase Type B Inhibitor in Parkinson’s disease Many of the prominent symptoms of Parkinson’s disease are due to a deficiency of striatal dopamine that is the consequence of a progressive degeneration and loss of a population of dopaminergic neurons which originate in the substantia nigra of the midbrain and project to the basal ganglia or striatum

The medical management for Parkinson’s disease includes:

• Levodopa therapies: to increase dopamine levels in the brain, which can help alleviate symptoms such as resting tremor, rigidity, and bradykinetic movements 2
• Selective Monoamine Oxidase Type B (MAO-B) inhibitors: such as selegiline, which can increase the net amount of dopamine available by blocking its catabolism, and can be used as an adjunct to levodopa/carbidopa therapy 3 Key points to consider:
• Dopamine replacement: levodopa therapies aim to replace dopamine in the brain, while MAO-B inhibitors aim to increase the availability of dopamine
• Combination therapy: selegiline can be used in combination with levodopa/carbidopa to enhance its effects and reduce side effects 3

From the Research

Medical Management for Parkinson's Disease

The medical management for Parkinson's disease (PD) is multifaceted and involves a combination of pharmacologic and nonpharmacologic approaches 4, 5, 6, 7, 8.

• Pharmacologic Treatment: The primary goal of pharmacologic treatment is to improve motor and nonmotor symptoms. Dopamine-based therapies, such as levodopa, are commonly used to manage initial motor symptoms 6, 7.
• Nonpharmacologic Treatment: Nonpharmacologic approaches, including exercise, physical, occupational, and speech therapies, complement pharmacologic treatments and help improve motor and nonmotor symptoms 4, 5.
• 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, 5.
• Palliative Care: Palliative care is an essential part of PD management, focusing on improving the quality of life for patients and their families 4.
• Treatment Approaches: Treatment approaches vary depending on the disease stage, symptom severity, and patient characteristics. A tailored pharmacotherapeutic and nonpharmacologic approach is necessary for each patient 5, 8.

Disease Variants and Prognosis

PD has multiple disease variants with different prognoses 4.

• Diffuse Malignant Subtype: Individuals with this subtype have prominent early motor and nonmotor symptoms, poor response to medication, and faster disease progression.
• Mild Motor-Predominant Parkinson Disease: Individuals with this subtype have mild symptoms, a good response to dopaminergic medications, and slower disease progression.
• Intermediate Subtype: Individuals with this subtype have a mix of motor and nonmotor symptoms, and their response to treatment varies.

Motor and Nonmotor Symptoms

PD is characterized by both motor and nonmotor symptoms 4, 8.

• Motor Symptoms: Motor symptoms include tremor, rigidity, bradykinesia, and postural instability.
• Nonmotor Symptoms: Nonmotor symptoms include constipation, cognitive decline, depression, anxiety, and sleep disturbances.