This page was printed from the Northern & Eastern Devon Formulary and Referral site at
Please ensure you are using the current version of this document
See section 4.9 Drugs used in parkinsonism and related disorders for drug choices
Northern Devon Healthcare Trust: Acute Medicines Management of Inpatients with Parkinson's Disease Guideline
There is currently no curative therapy and treatment is aimed at symptom alleviation and restoring or improving quality of life.
Correct diagnosis of the many Parkinsonian and tremulous syndromes may be difficult, but is very important before the selection of appropriate therapies.
Patients with Parkinsonism should be referred untreated to the movement disorder team, or other appropriate specialist, for diagnosis and assessment prior to starting drug therapy.
There is often no immediate need to start medication in newly diagnosed patients. Decisions should be made after discussions between the patient, their carer and the clinician about the degree of disability and the pros and cons of starting drug therapy.
In general, start only one new class of medication at a time. Dose titration should always be gradual - antiparkinsonian medication should never be started or stopped suddenly. It may take up to 3 months on a therapeutic dose before the full symptomatic benefits become apparent.
The following summaries reflect the treatment options for the vast majority of patients.
Early Parkinson's disease (treatment naïve) options:
Later Parkinson's disease (already on levodopa therapy) options:
Successful long-term management requires multidisciplinary care and a team approach involving the General Practitioner, hospital specialist, district nurse and Parkinson's Disease Nurse Specialist (PDNS) together with the patient and their carer(s). The skills and services of the physiotherapist, speech and language therapist, occupational therapist, clinical psychologist and pharmacist are likely to be required at various stages of the disorder. Access to nutrition and dietetic services, skilled dental care and health information and educational services are also needed as part of the team.
Antimuscarinics are sometimes used in patients under 50. They should be used with caution in those 50-60 years and are best avoided in those over 60. Use is limited by anticholinergic side effects, particularly disorientation, confusion, hallucinations and memory disturbance in older patients.
Small doses may be just as effective as larger ones; doses should be increased or decreased slowly.
Although antimuscarinics may be effective at suppressing Parkinsonian tremor, there is no evidence to suggest they are more effective than levodopa preparations.
Dopamine agonists may be used for tremor either alone or as an adjunct to other antiparkinsonian therapies. There are unconfirmed suggestions that some dopamine agonists may be more useful for treating tremor than others.
Domperidone 10mg to 20mg is the antiemetic of choice in Parkinson's disease as it cannot easily cross the blood-brain barrier and cause additional motor disturbances. The usual starting dose required for drug-induced nausea or vomiting is 20mg three times daily, but higher doses may sometimes be required initially. During drug titration with dopamine agonists or levodopa products, domperidone may need to be continued for up to 3 months, or until the patient is established on a therapeutic dose of dopamine agonist or levodopa.
Metoclopramide and prochlorperazine should be avoided in patients with Parkinson's disease.
See section 4.6 Drugs used in nausea and vertigo
Depression occurs in 40-50% of patients and can easily be overlooked. Limited studies have been performed to identify the best antidepressant in this disorder. It would seem prudent to commence with the tricyclics before the use of the SSRIs. Note that selegiline interacts with most antidepressants.
Anxiety is an extremely common feature and may be difficult to manage. Management may involve drug treatment and psychological treatments.
Constipation is nearly always present in Parkinson's disease and after basic advice about adequate fluid and fibre intake is most effectively treated with a stimulant laxative such as docusate, bisacodyl or senna. The addition of a bulk forming laxative (e.g. ispaghula husk or sterculia) and/or an osmotic laxative such as macrogol '3350' (e.g. CosmoCol®) may also be required (see section 1.6 Laxatives).