Parkinson's Disease
Treatment Decision-Making
Early Disease
The central questions in commencing treatment of PD are when to begin, and with what agent or combination of agents.
Potential Neuroprotection
If and when a clearly neuroprotective agent is identified, it will likely become the first treatment offered, and will be started as early in the course of the disease as possible. As of late 2006, no agent has been definitively shown to offer neuroprotection. Selegiline has a mild symptomatic effect, and is often used early for this reason, as well as its equivocal and much debated effects on slowing disease progression. Rasagiline is also used for the same purposes, based on its proven mild symptomatic effect and suggestion of a disease-slowing effect from a single trial. Coenzyme Q10, available over the counter, is also used early, based on a single trial whose results suggested a mild neuroprotective effect. Most PD experts believe the results of this trial are too preliminary and not robust enough to change early treatment practices without replication.
Commencing Symptomatic Therapy
The decision as to when to begin symptomatic therapy is an individual one made between patient and physician. Factors include:
- Degree of functional impairment
- Effect of symptoms on employment
- Patient attitudes towards medications
Fully educating the patient regarding the benefits and limitations of specific therapies allows the patient to be a full partner in the decision-making process. The obvious benefits of this collaborative decision-making process are especially important in PD, since treatment must be reevaluated and adjusted so often during the course of the disease, based on the changing condition of the patient and the response to previous therapy. It is in the interest of both patient and physician to develop such a partnership from the very beginning.
Initial Treatment Options
The choice of initial treatment is strongly influenced by patient age and condition. Levodopa is the usual treatment of choice in the elderly patient, because of its lower risk for psychiatric complications as compared to dopamine agonists. A dopamine agonist may be preferable in the younger patient, who is likely to be more tolerant of its side effects, and for whom delaying motor complications is an important goal, given the longer treatment horizon. An MAO-B inhibitor, amantadine, or an anticholinergic may also be appropriate initial treatment for mild symptoms, provided the side effects can be tolerated.
Depression and anxiety may also be early debilitating symptoms, and therefore can become the object of initial therapy.
