From the Guidelines
The most effective treatment for parkinsonism involves a combination of medications, including levodopa, and supportive therapies, with a focus on maximizing levodopa absorption and efficacy through dietary regimens, such as protein redistribution, as recommended by the ESPEN guideline 1.
Treatment Approach
The primary medication for parkinsonism is levodopa, usually combined with carbidopa (Sinemet) to prevent peripheral side effects, starting at 25/100 mg three times daily and gradually increasing as needed.
- Other medication options include:
- Dopamine agonists like pramipexole (Mirapex) or ropinirole (Requip)
- MAO-B inhibitors such as selegiline (Eldepryl) or rasagiline (Azilect)
- COMT inhibitors like entacapone (Comtan)
Dietary Considerations
In addition to medication, dietary regimens can play a crucial role in maximizing levodopa absorption and efficacy.
- The ESPEN guideline recommends advising patients experiencing motor fluctuations to try complying with a protein-redistribution dietary regimen, which involves redistributing protein intake throughout the day, with a low-protein breakfast and lunch, and consuming a second course with no quantitative restrictions in terms of protein only at dinner 1.
- This approach has been shown to improve motor function and disability and increase the duration of the "ON" state, particularly when the intervention is proposed to patients in the early stages of parkinsonism and with onset of parkinsonism in younger age.
Supportive Therapies
Supportive therapies, such as physical therapy, occupational therapy, and speech therapy, are essential components of treatment to maintain mobility, independence, and communication abilities.
- Regular exercise, particularly activities like tai chi or swimming, helps maintain flexibility and balance.
- Treatment should be individualized based on the patient's age, symptom severity, and other health conditions.
Recent Guidelines
Recent guidelines, such as the American Academy of Sleep Medicine clinical practice guideline, recommend the use of agents like clonazepam, immediate-release melatonin, pramipexole, and rivastigmine for the treatment of isolated REM sleep behavior disorder, which is often associated with parkinsonism 1.
- However, the primary focus of treatment for parkinsonism remains on managing symptoms through a combination of medications and supportive therapies, with a focus on maximizing levodopa absorption and efficacy.
From the FDA Drug Label
One of the two early Parkinson's disease studies (N=335) was a double-blind, placebo-controlled, parallel trial consisting of a 7 week dose escalation period and a 6 month maintenance period. The mean improvement from baseline on the UPDRS part II (ADL) total score was 1.9 in the group receiving pramipexole dihydrochloride tablets and -0. 4 in the placebo group, a difference that was statistically significant. The mean improvement from baseline on the UPDRS part III total score was 5.0 in the group receiving pramipexole dihydrochloride tablets and -0. 8 in the placebo group, a difference that was also statistically significant. A statistically significant difference between groups in favor of pramipexole dihydrochloride tablets was seen beginning at week 2 of the UPDRS part II (maximum dose 0.75 mg/day) and at week 3 of the UPDRS part III (maximum dose 1. 5 mg/day).
Treatment for Parkinsonism:
- Pramipexole dihydrochloride tablets are effective in the treatment of parkinsonism, as shown by statistically significant improvements in UPDRS part II and III total scores compared to placebo 2.
- The recommended dose of pramipexole dihydrochloride tablets is not explicitly stated in the provided text, but the maximum dose used in the studies was 4.5 mg/day in three divided doses.
- Selegiline may also be used as an adjunct to levodopa/carbidopa in the treatment of parkinsonism, but its effectiveness as a sole treatment is unknown 3.
From the Research
Treatment Options for Parkinsonism
- The primary goal of treatment for Parkinson's disease is to improve motor and nonmotor symptoms, as there are no disease-modifying pharmacologic treatments available 4.
- Dopamine-based therapies, such as levodopa preparations, are typically used to help initial motor symptoms, while nonmotor symptoms require nondopaminergic approaches 4.
- Rehabilitative therapy and exercise can complement pharmacologic treatments, and advanced treatments like deep brain stimulation may be beneficial for individuals with medication-resistant tremor or dyskinesias 4, 5.
Pharmacologic Treatments
- Levodopa combined with carbidopa is still the most effective treatment for symptoms of Parkinson's disease 5.
- Dopamine agonists can be used alone before the introduction of levodopa or as an adjunct to levodopa, and may be indicated for younger patients with relatively mild symptoms 5, 6.
- Addition of a peripherally-acting COMT inhibitor or an MAO-B inhibitor to levodopa can reduce motor fluctuations in patients with advanced disease 5.
- Amantadine may have mild symptomatic benefit and can decrease levodopa-induced dyskinesias, while anticholinergics can be a useful addition to levodopa for control of tremor and drooling 5.
Non-Pharmacologic Treatments
- Patient education and counseling are essential, especially concerning prognosis, future symptoms, and treatment options 6.
- Exercise and physical, occupational, and speech therapies can complement pharmacologic treatments and improve quality of life 4.
- Deep brain stimulation is an option for patients with levodopa-induced motor complications and relatively intact cognition 5.
Initiating Treatment
- The decision of when to initiate treatment should be based on individual assessment of the risks and benefits of available antiparkinsonian medications 7.
- Treatment should be started when the patient is beginning to be disabled, which varies from patient to patient and depends on age, employment status, and other factors 6.
- The choice of a specific drug should be dictated by the patient's symptoms, and non-motor symptoms such as anxiety and depression should be managed accordingly 6.