The American Academy of Neurology (AAN) has published a new guideline for initiation of dopaminergic treatment of motor symptoms of early Parkinson’s disease.

Last published in 2002, the new practice guideline released yesterday, call for counselling of patients about the benefits and risks of starting treatment options namely levodopa, dopamine agonists and monoamine oxidase B (MAO-B) inhibitors, to make informed decision about the best treatment plan for them. The primary motor symptoms in early stages of the disease include tremors, rigidity and bradykinesia.

Levodopa is the first option when starting therapy for most patients with early PD, preferably with immediate-release (IR) levodopa instead of long-acting forms of levodopa or levodopa/carbidopa/entacapone. The guideline states, “Initial treatment with levodopa provides superior motor benefit compared to treatment with dopamine agonists.” Begin with the minimum dose of levodopa to minimize the risk of dyskinesia. Patients should be educated about the chances of dyskinesia with higher doses of levodopa.

In patients older than 60 years at risk for dyskinesia, dopamine agonists may be selected as the initial treatment. However, the guideline recommends against prescribing dopamine agonists in patients above 70 years of age, those with ICDs, cognitive impairment, excessive daytime sleepiness or hallucinations.

Regularly monitor patients for drug efficacy and adverse effects. Dyskinesia is more likely to occur with levodopa than with dopamine agonists during the first 5 years of treatment. While dopamine agonists may cause hallucinations, excessive daytime sleepiness or impulse-control disorders (such as compulsive gambling, eating, shopping). Compared to levodopa, adherence to dopamine agonists and MAO-B inhibitors is poor, with many patients discontinuing the treatment. Since, patients may not always report adverse effects, it is for the physicians to enquire about them for timely recognition of adverse effects. Tapering or discontinuation of medication may be considered in such a situation.

As Tamara Pringsheim, MD, University of Calgary in Alberta, Canada and coauthor of the guideline said, “Choosing to start a medication is a collaborative decision between a person with Parkinson’s disease, their neurologist, and their caregiver. The right medication will depend on a person’s symptoms, age and life circumstances.”

The complete practice guideline is published in the journal Neurology.

Reference

1. Pringsheim T, et al; Guideline Subcommittee of the AAN. Dopaminergic Therapy for Motor Symptoms in Early Parkinson Disease Practice Guideline Summary A Report of the AAN Guideline Subcommittee. Neurology Nov 2021, 97 (20) 942-957; DOI: 10.1212/WNL.0000000000012868