Parkinson's disease management

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

Principles of treatment

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:

  • Levodopa alone
  • Dopamine agonist +/- Levodopa
  • Monoamine-oxidase-B inhibitor +/- Levodopa

Later Parkinson's disease (already on levodopa therapy) options:

  • Monoamine-oxidase-B inhibitor +/- levodopa
  • Dopamine agonist + Levodopa
  • Catechol-O-methyltransferase inhibitor (COMTI) + Levodopa

See section 4.9 Drugs used in parkinsonism and related disorders

Non-pharmacological therapies and reablement

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.

Parkinsonian tremors

  • A tremor due to Parkinson's disease is most likely to be a 4-6Hz resting tremor, often with a unilateral or asymmetric onset. There are, however, several common pitfalls.
  • Not all patients with Parkinson's disease have a tremor and despite tremor being one of the cardinal features of Parkinson's disease, it is not necessary for the diagnosis.
  • Some Parkinson's disease patients have a postural component to their resting tremor.
  • Some patients present with a postural tremor alone, especially in the early course of the disease.
  • Head tremor is very unusual in Parkinson's disease, although a jaw tremor may occur.
  • There remains some debate about the relationship between Parkinson's disease and essential tremor and the possible overlap between the two disorders.

Antimuscarinics

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.

Trihexyphenidyl

Dose

  • Starting dose 1mg daily increased slowly. Up to 5mg four times daily if needed.
Alternatives include
Orphenadrine
Procyclidine

Dopamine release enhancer

Amantadine

Dose

  • Starting dose 100mg daily. Increase after one to two weeks to 100mg twice daily

Notes

  1. Amantadine may be helpful for Parkinsonian tremor in a small proportion of patients. May be used alone or to supplement the action of other antiparkinsonian drugs. May also be helpful in Parkinsonian dyskinesias.
  2. Amantadine has been reported to be associated with an increased risk of valvular heart disease. As with dopamine agonists, echocardiographic monitoring may be required.

Dopamine receptor agonists

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.

See section 4.9 Drugs used in parkinsonism and related disorders

Pramipexole
Ropinirole
Piribedil

Management of nausea and vomiting

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

Other problems associated with Parkinson's disease

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).

 

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