Treatment:

Drugs, physical therapy, and surgical interventions can manage Parkinson's disease. The goals of treatment for Parkinson's disease are to:

• Relieve disabilities
• Balance the problems of the disease with the side effects of the medications

Treatment is very individualized for this complicated disease. Patients must work closely with doctors and therapists throughout the course of the disease to customize a program suitable for their particular and changing needs. Patients should never change their medications without consulting their doctor, and they should never stop taking their medications abruptly.

No treatment method has been shown to change the course of the disease. For early disease with little or no impairment, active treatment with medications may not be necessary.

A number of issues must be considered in choosing medication treatment. These include how effective a specific drug group is in treating symptoms, which symptoms are predominant, side effect profile, loss of effectiveness over time, and other considerations.

Treatments for Onset of Parkinson's Disease

The American Academy of Neurology recommends the following therapies for the initial treatment of Parkinsonâ ' s disease:

Levodopa (L-dopa). Levodopa, or L-dopa, has been used for years and is the gold standard for treating Parkinson's disease. L-dopa increases brain levels of dopamine. It is probably the most effective drug for controlling symptoms and is used in nearly all phases of the disease. The standard preparations (Sinemet, Atamet) combine levodopa with carbidopa, a drug that slows the breakdown of levodopa. Levodopa is better at improving motor problems than dopamine agonists but increases the risk of involuntary movements (dyskinesia). Effectiveness tends to decrease after 4 - 5 years of usage.

Dopamine Agonists. Dopamine agonist drugs mimic dopamine to stimulate the dopamine system in the brain. These drugs include pramipexole (Mirapex), ropinirole (Requip), and bromocriptine (Parlodel). The Food and Drug Administration (FDA) pulled the dopamine agonist pergolide (Permax) from the market in 2007 over safety concerns that included potentially fatal heart valve damage. In 2008, a skin patch dopamine agonist, transdermal rotigotine (Neupro), was recalled from the market.

Selegiline (Eldepryl) and Rasagiline (Azilect). Selegiline is a monoamine oxidase B (MAO-B) inhibitor that may have some mild benefit as an initial therapy. However, unlike levodopa, it does not slow the progression of Parkinson's disease. Rasagiline (Azilect) is another MAO-B inhibitor used for treatment of Parkinsonâ ' s.

Treatments for Off Time

Drug treatments for Parkinson disease do not consistently control symptoms. At certain points during the day, the beneficial effects of drugs wear off, and symptoms can return, including uncontrolled muscular motor function, difficulty walking, and loss of energy. The American Academy of Neurology (AAN) has reviewed evidence for the various drugs used to treat “off time" and found that the following drugs have the strongest evidence for controlling off time symptoms:

• Entacapone (Comtan) belongs to a class of drugs called catechol-o-methyl transferase (COMT) inhibitors. COMT inhibitors help prolong the effects of levodopa by blocking an enzyme that breaks down dopamine.
• Rasagiline (Azilect) belongs to a class of drugs called monoamine oxidase (MAO) inhibitors. These drugs slow the breakdown of dopamine that occurs naturally in the brain and dopamine produced from levodopa.

The AAN also finds good evidence for the dopamine agonists ropinirole (Requip) and pramipexole (Mirapex), and the COMT inhibitor tolcapone (Tasmar). Deep brain stimulation is a surgical treatment that may help improve motor fluctuations in some patients.

Treatments for Other Symptoms of Parkinson's

Conditions associated with motor impairment and other symptoms of Parkinson's disease may need a variety of treatments.

Depression. Although depression is very common in PD, there have been surprisingly few controlled studies. Antidepressants used for PD include tricyclics, particularly amitriptyline (Elavil). Some studies have found that selective serotonin-reuptake inhibitors (SSRIs) -- which include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) -- may worsen symptoms of Parkinson's. Doctors should monitor patients taking SSRIs.

Psychotic Side Effects. Studies indicate that clozapine (Clozaril) and quetiapine (Seroquel), antipsychotic drugs used to treat schizophrenia, may be the best drugs for treating psychosis in patients with Parkinson's disease. A similar drug, olanzapine (Zyprexa), should not be used for patients with PD because it can worsen their psychotic symptoms.

Dementia. The cholinesterase inhibitor drugs donepezil (Aricept) and rivastigmine (Exelon) are used to treat Alzheimerâ ' s disease. Studies show the actual clinical improvement is very modest at best.

Daytime Sleepiness. Modafinil (Provigil), a drug used to treat narcolepsy may be helpful for patients with sleepiness related to their disease.

Erectile Dysfunction. Sildenafil (Viagra) can be helpful for men with Parkinson's disease who suffer from impotence. However, the drug may worsen orthostatic hypotension (lightheadedness or dizziness that occurs when suddenly standing up), a side effect of some PD medications.

Treating Advanced Disease

Advanced Parkinsonâ ' s disease poses challenges for both patients and caregivers. Eventually, symptoms such as stooped posture, freezing, and speech difficulties may no longer respond to drug treatment. Surgery (deep brain stimulation) may be considered for some patients. Patients become increasingly dependent on others for care and require assistance with daily tasks. Modifications (wheelchair ramps, grab bars and handrails) may need to be made in the home. Some patients may need to move to an assisted living facility or nursing home. The goal of treatment for advanced Parkinsonâ ' s disease should be on providing patients with safety, comfort, and quality of life.