What is the standard treatment protocol for Parkinsonism in India?

Standard Treatment Protocol for Parkinsonism in India

Levodopa/carbidopa is the most effective first-line medication for treating Parkinson's disease and should be the primary treatment for most patients in India. 1, 2, 3

Initial Treatment Approach

• Levodopa is the most effective drug for treating motor symptoms of Parkinson's disease and should be offered as first-line therapy for most newly diagnosed patients 1, 4
• For younger patients where maintaining employment or physical activity is important, levodopa should be considered early, either as monotherapy or in combination with other drugs 5
• Dopamine agonists may be used as initial therapy in some cases, particularly in younger patients, but provide less effective symptom control compared to levodopa 6

Optimizing Levodopa Administration

• Patients should take levodopa medications at least 30 minutes before meals to avoid interactions with dietary proteins that reduce absorption and efficacy 1, 3
• For patients experiencing motor fluctuations, implementing a protein redistribution diet (low-protein breakfast and lunch, normal protein intake at dinner) improves motor function and increases "ON" time 1, 3
• The recommended daily protein intake should be 0.8-1.0 g/kg of body weight 1
• Monitor for potential complications of protein redistribution including weight loss, micronutrient deficits, hunger before dinner, and dyskinesias 1, 3

Managing Motor Complications

• For patients with troublesome dyskinesias, reducing levodopa doses may be considered 1, 3
• Adding a catechol-O-methyltransferase (COMT) inhibitor like entacapone can improve levodopa bioavailability and help manage wearing-off effects 5, 7
• Triple combination of levodopa/carbidopa/entacapone available in a single tablet offers flexibility and helps control response fluctuations 5
• Deep brain stimulation (DBS) can be considered for advanced motor fluctuations resistant to oral medication adjustments 1, 3

Deep Brain Stimulation Considerations

• When considering DBS for advanced PD, either subthalamic nucleus (STN) or globus pallidus internus (GPi) targets can be selected for treating motor symptoms 1, 3
• STN DBS should be preferred when medication reduction is a primary goal 1
• If there are significant concerns about cognitive decline, GPi DBS may be preferable 1, 2, 3
• If there is significant concern about depression risk, GPi stimulation should be considered over STN 1

Management of Non-Motor Symptoms

• For REM sleep behavior disorder (RBD) associated with Parkinson's disease:
  • Clonazepam (0.5-2.0 mg 30 minutes before bedtime) is commonly used but has side effects including morning sedation, gait imbalance/falls, depression, and cognitive disturbances 8, 3
  • Melatonin (3-12 mg at bedtime) is recommended, especially for older patients, as it is only mildly sedating 8, 2, 3
  • Rivastigmine may be appropriate for patients with RBD and cognitive impairment refractory to other treatments 3

Nutritional and Swallowing Management

• Medical nutrition therapy should be provided to improve well-being and quality of life, tailored to individual requirements 1
• For patients with dysphagia, rehabilitation treatment should be advised after multidimensional assessment of swallowing function 8, 1
• Patients on levodopa should be monitored for homocysteine levels and vitamin B status, as levodopa can cause hyperhomocysteinemia 1, 3
• Monitor for side effects of PD medications that might influence nutritional status, including nausea, vomiting, abdominal pain, dyspepsia, constipation, weight decrease, dry mouth, and anorexia 1, 3
• Patients with constipation may benefit from fermented milk with probiotics and prebiotic fiber, in addition to increased water and fiber intake 3

Common Pitfalls and Caveats

• Strict low-protein diets are not supported by evidence and should be avoided 1, 3
• Gluten-free or plant-food-based diets lack evidence for managing motor fluctuations in PD 1
• For tube-fed patients on oral levodopa, interrupt enteral nutrition for at least 1 hour before and 30-40 minutes after medication administration 1, 3
• Increasing doses of levodopa over time are associated with higher risk for malnutrition, requiring careful monitoring 1, 2, 3
• Dopamine agonist monotherapy may lead to inadequate symptom control compared to levodopa, despite potential benefits in delaying motor complications 6