What is the treatment for patients with shaking or Parkinson's-like symptoms?

From the Guidelines

Treatment for patients with shaking or Parkinson's-like symptoms typically involves medication therapy, with levodopa-carbidopa being the gold standard treatment, as evidenced by the most recent and highest quality study 1.

Medication Therapy

The usual starting dose of levodopa-carbidopa is 25/100 mg three times daily, which can be adjusted based on symptom control. Other medications include dopamine agonists like pramipexole or ropinirole, MAO-B inhibitors such as selegiline, and COMT inhibitors like entacapone.

• Dopamine agonists: pramipexole (Mirapex) or ropinirole (Requip)
• MAO-B inhibitors: selegiline (Eldepryl)
• COMT inhibitors: entacapone (Comtan)

Complementary Treatments

Physical therapy, occupational therapy, and speech therapy are important complementary treatments to maintain function and quality of life.

• Physical therapy to improve mobility and balance
• Occupational therapy to maintain daily functioning
• Speech therapy to address communication difficulties

Determining the Exact Cause of Tremors

It's essential to determine the exact cause of tremors, as not all shaking is due to Parkinson's disease; essential tremor, for example, is treated differently, often with propranolol (20-40 mg twice daily) or primidone (50-250 mg daily) 1.

• Essential tremor: propranolol (20-40 mg twice daily) or primidone (50-250 mg daily)
• Parkinson's disease: levodopa-carbidopa, dopamine agonists, MAO-B inhibitors, and COMT inhibitors

Severe Cases

For severe cases unresponsive to medication, deep brain stimulation surgery may be considered, as recommended by the American Academy of Sleep Medicine 1.

• Deep brain stimulation surgery for severe cases

Dietary Management

Dietary management, such as protein redistribution, may also be beneficial in maximizing levodopa absorption and efficacy, as suggested by the ESPEN guideline on clinical nutrition in neurology 1.

• Protein redistribution to maximize levodopa absorption and efficacy
• Low-protein diet may not be recommended due to potential complications such as weight loss and micronutrient deficits 1

From the FDA Drug Label

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 Current evidence indicates that symptoms of Parkinson’s disease are related to depletion of dopamine in the corpus striatum. Administration of dopamine is ineffective in the treatment of Parkinson’s disease apparently because it does not cross the blood-brain barrier However, levodopa, the metabolic precursor of dopamine, does cross the blood-brain barrier, and presumably is converted to dopamine in the brain. This is thought to be the mechanism whereby levodopa relieves symptoms of Parkinson’s disease

The treatment for patients with shaking or Parkinson's-like symptoms is levodopa therapy. This is because levodopa can cross the blood-brain barrier and is converted to dopamine in the brain, which helps to relieve symptoms of Parkinson's disease, including shaking and tremors.

• Key points:
  • Levodopa is a metabolic precursor of dopamine
  • Levodopa crosses the blood-brain barrier and is converted to dopamine in the brain
  • Levodopa relieves symptoms of Parkinson's disease, including shaking and tremors
  • Carbidopa can be administered with levodopa to reduce the amount of levodopa required and increase its availability to the brain 2
  • Ropinirole, a dopamine agonist, can also be used to treat Parkinson's disease, but it has a different mechanism of action and may have different side effects 3

From the Research

Treatment Options for Shaking and Parkinson's-like Symptoms

• The treatment for patients with shaking or Parkinson's-like symptoms is symptomatic, focused on improving motor and nonmotor signs and symptoms 4.
• Dopamine-based therapies, such as levodopa preparations, are typically used to help initial motor symptoms, while nonmotor symptoms require nondopaminergic approaches 4, 5.
• For essential tremor, medical treatment options include beta blockers, anticonvulsants, benzodiazepines, and carbonic anhydrase inhibitors 5.
• For Parkinson's disease, levodopa is the mainstay of pharmacologic therapy, although other agents, such as dopamine agonists, amantadine, anticholinergics, selegiline, and COMT inhibitors, may also be used 5, 6.
• In cases of tremor-predominant Parkinson's disease, first-line medications, such as levodopa, dopamine agonists, and anticholinergics, may be effective in controlling tremor, while second-line medications, such as clozapine, amantadine, clonazepam, propranolol, and neurontin, may be used for patients who are unresponsive to first-line drugs 6.
• For patients with disabling tremor that is refractory to all medications, neurosurgical intervention, such as deep brain stimulation, may be considered 6, 7.

Pharmacologic Treatment of Tremor

• Beta-adrenergic blockers and primidone are commonly used to treat essential tremor, while carbidopa/levodopa and anticholinergics are most beneficial in Parkinson's disease 7.
• Other medications, such as dopamine agonists, amantadine, and selegiline, may also be used to treat tremor in Parkinson's disease 4, 5, 8.

Initiating Therapy for Parkinson's Disease

• Initiating pharmacologic therapy for Parkinson's disease must take into consideration the degree of dysfunction the patient is experiencing, the question of neuroprotection, the degree of motor response required, and the potential complications of long-term treatment 8.
• Either dopamine agonists or levodopa may be initiated, with dopamine agonists associated with fewer motor fluctuations and dyskinesias, and levodopa associated with better motor performance 8.