What is the management of Parkinson's disease (PD)?

Management of Parkinson's Disease

The management of Parkinson's disease requires a comprehensive approach focusing on both pharmacological and non-pharmacological interventions, with levodopa/carbidopa as the cornerstone of treatment, supplemented by additional therapies for motor fluctuations and non-motor symptoms as the disease progresses.

Initial Pharmacological Management

• Levodopa/carbidopa is the most effective medication for controlling motor symptoms of Parkinson's disease and should be administered with careful attention to timing and dietary considerations 1
• For optimal absorption, administer levodopa at least 30 minutes before meals to avoid competition with dietary proteins 1
• Consider a protein redistribution diet (low-protein breakfast and lunch, normal protein intake at dinner) to improve motor function and increase "ON" time 1
• Monitor for hyperhomocysteinemia, especially in older patients, those with long-standing disease, and patients with low serum levels of vitamin B12 and folate 2, 1
• Supplement with vitamin B12 and folate to maintain normal homocysteine levels, as high homocysteine levels have been linked to cardiovascular diseases, dementia, and depression 2

Management of Motor Fluctuations

• For patients experiencing "wearing off" phenomena, consider adding adjunctive therapies:
  • MAO-B inhibitors (e.g., selegiline) to block dopamine catabolism and increase available dopamine 3, 4
  • COMT inhibitors (e.g., opicapone) to extend levodopa benefit 4
  • Dopamine agonists including apomorphine for rescue therapy during "OFF" periods 5, 4
• Apomorphine subcutaneous infusion has demonstrated significant reduction in daily OFF time (2.55 hours vs. 0.90 hours with placebo) and increase in ON time without troublesome dyskinesia (2.76 hours vs. 1.12 hours with placebo) 5

Advanced Disease Management

• For patients with medication-resistant symptoms, motor fluctuations, and dyskinesias that cannot be adequately controlled with oral medications, consider device-aided therapies 6, 4:
  • Levodopa/carbidopa intestinal gel infusion for more continuous dopaminergic stimulation 4
  • Deep brain stimulation (DBS), particularly targeting the subthalamic nucleus or internal globus pallidus 7, 8
  • MRI-guided focused ultrasound as a less invasive surgical option for selected patients 4, 7

Non-Motor Symptom Management

• Dysphagia management should include rehabilitation treatment with adapting bolus characteristics, postural maneuvers, and exercise programs after multidimensional assessment of swallowing function 2
• For constipation, increase water and fiber intake, and consider fermented milk with probiotics and prebiotic fiber 1
• For psychiatric symptoms (depression, anxiety), use selective serotonin reuptake inhibitors 6
• For cognitive symptoms, consider cholinesterase inhibitors 6
• For pain management, use a multimodal approach including cognitive behavioral therapy and exposure-based treatments 2

Rehabilitation and Supportive Care

• Exercise and physical therapy are essential complementary treatments to pharmacological interventions 6, 9
• Occupational therapy helps maintain independence in activities of daily living 9
• Speech therapy addresses communication difficulties 9
• Palliative care should be integrated throughout disease management 6

Special Considerations

• When using MAO-B inhibitors like selegiline, be aware of potential interactions with tyramine-containing foods and sympathomimetic medications, although these are rare at the recommended dose of 10 mg/day 3
• For patients with 22q11.2 deletion syndrome and Parkinson's disease, use a "start low, go slow" approach to medication dosing due to increased risk of seizures and other neurological complications 2
• Address health disparities in Parkinson's disease care, particularly for patients from disadvantaged populations who may have limited access to specialized care 2

Monitoring and Follow-up

• Regular monitoring of calcium, parathyroid hormone, and other metabolic parameters is important, especially in patients with comorbidities 2
• Longitudinal follow-up is crucial to adjust treatment as the disease progresses 2
• Assess for development of motor complications and adjust therapy accordingly 4, 9