Initiating Treatment for Parkinson’s Disease

Abstract

There are many options available for initiating medical therapy of Parkinson’s disease. Rather than treating all patients the same by relying on an algorithmic approach, treatment should be individualized based on the specific needs of each patient. The decision regarding when treatment is necessary is dictated by the degree to which PD is interfering with the patient’s functioning or affecting them psychosocially, such as embarrassment. All patients with PD will eventually require treatment with levodopa, but for younger patients with mild impairment, options also include a dopamine agonist, an anticholinergic, a monoamine B inhibitor, or amantadine; the choice should be a mutual decision with the patient after discussing the pros and cons of each drug. For the patient in whom PD is significantly affecting functioning, especially their occupation, levodopa is usually the best option, even for the younger patient as the benefit of levodopa outweighs the increased risk of fluctuations and dyskinesias. While initial therapy with a dopamine agonist forestalls fluctuations, this comes at the expense of less symptom relief and greater side effects. Levodopa should be considered the first-line agent for patients over 70 as older patients are less likely to develop fluctuations and dyskinesias. The often-practiced reticence of initiating treatment of PD with levodopa is no longer justified.