Parkinson's Disease - Treatment

Highlights	Diagnosis	Lifestyle Changes
Introduction	Treatment	Resources
Symptoms	Levadopa (L-dopa)	References
Risk Factors	Medications
Complications	Surgery

Treatment

Parkinson's disease can be managed with drugs, physical therapy, and surgical interventions. The goals of treatment for Parkinson's disease are twofold:

To relieve disabilities.
To balance the problems of the disease with the side effects of the medications.

Treatment is very individualized for this complicated disease. Patients must work closely with physicians and therapists throughout the course of the disease to customize a program suitable for their particular and changing needs. Patients should never change their medications without consulting their physicians, and they should never stop taking their medications abruptly.

Treatments by Stage of Parkinson's Disease
Onset of Mild Symptoms	Lifestyle Changes (Exercise, Diet) Drugs (used alone): Amantadine Selegiline Anticholinergic (for tremor)
Onset of Moderate Symptoms	Levodopa (L-dopa) Dopamine agonists supplemented with L-dopa as necessary Selegiline Catechol-o-methyl transferase inhibitor (not effective alone)
Long-Term Maintenance: Drugs Used with L-Dopa	Effective: Dopamine agonists (pergolide, pramipexole, cabergoline, bromocriptine); Catechol-o-methyl transferase inhibitors (entacapone) Likely to be effective: Dopamine agonists (apomorphine, lisuride); amantadine; anticholinergics Investigational:Rasagiline, rotigotine, safinamide, piribedil, rivastigmine
Advanced Disease	Experimental Drugs Surgical or other procedures, usually deep brain stimulation

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Levodopa (L-Dopa)

Levodopa, or L-dopa, has been used for years and is the gold standard for treating Parkinson's disease. It is converted to dopamine in the brain and so acts as a replacement drug. It is used in nearly all phases of the disease. The standard preparation combines levodopa with an anti-nausea agent carbidopa (Sinemet, Atamet).

Treatments for Onset of Parkinson's Disease

There is no standard method for treating the earliest symptoms. Before symptoms become disabling, some patients prefer trying lifestyle changes first, including exercise and diet. When the patient and physician determine that medication is necessary, the patient will start out with as low a dose as possible of any drug used.

The timing and treatments for treatment of symptom onset may be as follows:

Significant symptoms in people over 70 are almost always first treated with L-dopa.
Moderate symptoms in younger adults, who will require treatment for decades, may be treated first with dopamine agonists. These agents make use of any residual natural dopamine rather than simply replacing it, as L-dopa does. When symptoms become pronounced or other drugs are no longer effective, then L-dopa is given to the patient. There is considerable debate, however, about delaying L-dopa treatment and using the newer dopamine agonists first in younger adults other than those with early-onset disease.

Early Use of Dopamine Agonists versus L-Dopa

According to 2001 guidelines, dopamine agonists should be used as the first treatment for most PD patients. Controversy still exists over their first use compared to L-dopa.

Arguments for Early Use of Dopamine Agonists. The basic motive for early use of dopamine agonists is to delay the complications of L-dopa, which tend to occur after five to fifteen years of treatment. Some studies reported that dopamine agonists can delay the onset of L-dopa complications by about a year. There is also some belief that L-dopa may harm nerve cells and become toxic over time.

Arguments for Early Use of L-Dopa. Experts who believe that L-dopa should be used early on in most adults are supported by the following arguments and studies:

There is some evidence that taking levodopa early in the course of the illness can prolong life. The effects of the other agents are still unknown.
The newer drugs still have not been proven to be better than L-dopa. Studies in 2000 reported, in fact, reported that although they control the disease effectively early on, L-dopa still appears to achieve better motor control. And, after three years, there is no difference in disease progression among patients taking any of these drugs.
The first five years of the disease is generally marked by mild symptoms. And, although dopamine agonists delay L-dopa complications, these drugs too can have severe side effects (such as nausea and hallucinations). Younger adults, then, who take L-dopa might have a better quality of life during those early years when they are most active.
It is well known that the effects of L-dopa begin to wear-off in increasingly shorter times the longer a patient has been on the drug. A 1999 controlled study reported, however, that the drug was still effective in 80% of patients after first five years of therapy. And other studies suggest that most patients, if not all, derive substantial benefit from the drug throughout their lives.