What is the recommended treatment for Parkinson's disease?

Recommended Treatment for Parkinson's Disease

Levodopa/carbidopa is the most effective medication for treating Parkinson's disease and should be the first-line treatment for most patients, with strategies to maximize its effectiveness including proper timing of medication and protein redistribution for patients experiencing motor fluctuations. 1, 2

First-Line Treatment Options

• Levodopa/carbidopa is recommended as the first-line treatment for most newly diagnosed Parkinson's disease patients as it is the most effective medication for treating motor symptoms 1, 2
• For patients requiring symptomatic treatment, levodopa provides the greatest improvement in motor function compared to other available medications 3, 4
• Taking levodopa at least 30 minutes before meals is recommended to avoid interactions with dietary proteins that reduce absorption and efficacy 1, 2

Optimizing Medication Administration

• Implementing a protein redistribution diet (low-protein breakfast and lunch, with normal protein intake at dinner) can improve motor function and increase "ON" time in patients experiencing motor fluctuations 1, 2
• The recommended daily protein intake should be 0.8-1.0 g/kg of body weight to maintain nutritional status while optimizing medication effectiveness 1
• Monitor for potential complications of protein redistribution including weight loss, micronutrient deficits, hunger before dinner, and dyskinesias 1, 2

Managing Motor Complications

• For patients with troublesome dyskinesias, reducing levodopa doses may be considered 1, 2
• As the disease progresses, increasing doses of levodopa may be necessary but are associated with a higher risk for malnutrition requiring careful monitoring 1, 2
• Deep brain stimulation (DBS) of either subthalamic nucleus (STN) or globus pallidus internus (GPi) can be considered for advanced Parkinson's disease with motor fluctuations resistant to oral medication adjustments 1, 2

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
• 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
• 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, melatonin (3-12 mg at bedtime) is recommended, especially for older patients 1, 2
• Clonazepam (0.5-2.0 mg 30 minutes before bedtime) is commonly used for RBD but has side effects including morning sedation, gait imbalance/falls, depression, and cognitive disturbances 1, 2
• Rivastigmine may be appropriate for patients with RBD and cognitive impairment refractory to other treatments 2

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 1
• Patients on levodopa should be monitored for homocysteine levels and vitamin B status, as levodopa can cause hyperhomocysteinemia 1, 2
• Patients with constipation may benefit from fermented milk with probiotics and prebiotic fiber, in addition to increased water and fiber intake 2

Common Pitfalls and Caveats

• Strict low-protein diets are not supported by evidence and should be avoided 1, 2
• For tube-fed patients on oral levodopa, interrupting enteral nutrition for at least 1 hour before and 30-40 minutes after medication administration is recommended 2
• Dopamine agonists like pramipexole can cause significant side effects including falling asleep during activities of daily living, hallucinations (particularly in patients over 65), and orthostatic hypotension 5
• Hallucinations are more common in older patients (>65 years) on dopamine agonists, with the risk being 5-7 times greater than placebo 5