Parkinsons
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Making therapy choices (based on EFNS guidelines)
Early Parkinson's disease[63]
It is not possible to identify a universal first-choice drug therapy for patients with early PD.
The choice of drug first prescribed should take into account.[18]
- Clinical and lifestyle characteristics
- Patient preference, after the patient has been fully informed of the short-term and long-term advantages and disadvantages of each drug class (Table 9).
Conventional levodopa
In early Parkinson's disease (PD), levodopa is the most effective symptomatic therapy for improving motor symptoms.
Levodopa provides better symptomatic control and compliance compared with dopamine agonists (DAs).
However, after a few years of treatment, conventional levodopa is frequently associated with the development of motor complications. The early use of a controlled-release formulation of levodopa is not effective in the prevention of these motor complications.
Older patients are less prone to developing motor complications; therefore,?conventional levodopa is the drug of choice for the treatment of these patients.
Dopamine agonists
Dopamine agonists are effective as monotherapy in early PD, with a lower risk of development of motor complications.
However, they are associated with a greater incidence of common side effects, such as hallucinations, somnolence and leg oedema, when compared with levodopa.
Patients must be informed of these risks, e.g. excessive daytime somnolence is especially relevant to drivers.
Ergot-derived DAs such as pergolide, bromocriptine and carbergoline are not recommended as first-line medication because of the risk of fibrotic reaction.
Monoamine oxidase B inhibitors
Monoamine oxidase (MAO)-B inhibitors offer ease of administration, but the symptomatic effects are modest compared with levodopa.
The evidence for neuroprotection with MAO-B inhibitors is insufficient to conclude that the effects are not merely symptomatic.
Adjustment of initial monotherapy in patients without motor complications
Adjustment of initial monotherapy is necessary over time because of worsening motor symptoms.
If patients are on DA therapy:
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Increase the DA dose; however, even when the DA dose is increased over time it cannot control parkinsonian symptoms in the medium-term and levodopa will eventually be required.
If patients are on conventional levodopa therapy:
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Increase the levodopa dose
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Add a DA, although the efficacy of adding an agonist has been insufficiently evaluated.