Modern treatment in Parkinson’s disease, a personal approach

Abstract

There are many guidelines available concerning the treatment of Parkinson's disease. Most of these advocate treating young-onset patients with a dopamine agonist and older patients with levodopa. The rationale behind this recommendation has its origins in the side effects associated with each of these drug classes: whilst levodopa leads to dyskinesia, which may not be relevant for patients with a limited life-expectancy, dopamine agonists have a much longer plasma half life which probably leads to more continuous dopamine receptor stimulation and thus decreases the occurrence and severity of dyskinesia. However, the side effects associated with the use of dopamine agonists, such as sleepiness, orthostatic problems, hallucinations and impulse control disorders are a drawback. In this overview, the hypothesis will be put forward that perhaps such a strict distinction is no longer needed. A new idea may be the early combination of levodopa with a dopamine agonist which would provide good clinical efficacy and, because of the relatively low doses involved, would reduce the side effects associated with both substances. MAO-B inhibitors may be a good option for early treatment and especially for patients who experience first motor fluctuations. Similarly, and particularly if a wearing-off symptom is present, COMT inhibitors smoothen and prolong the action of levodopa. More invasive escalation therapy comes into play when patients reach the advanced stages with problems of insufficient motor control, such as bradykinesia, rigidity and resting tremor, combined with on-time dyskinesia. The use of all oral and invasive treatment has to be individualized to gain a good motor and non-motor control and especially a good quality of life.

Fingolimod (FTY720) is not protective in the subacute MPTP mouse model of Parkinson's disease and does not lead to a sustainable increase of brain‐derived neurotrophic factor

“…). These findings indicate that fingolimod might be beneficial for non‐motor symptoms of PD symptoms, which are a primary therapeutic challenge in PD (Reichmann ).…”

Workforce participation and activities in Parkinson's disease patients receiving device-aided therapy

“…7,8 All 3 have the ability to apply a more continuous stimulation, thereby reducing motor fluctuations. 10,11 The EARLYSTIM study found improved QOL, compared to medical therapy, when introducing DBS in younger patients with PD. Randomized controlled studies have shown reduced time in "off" periods and increased time in "on" periods, without troublesome dyskinesia, in patients with PD with motor fluctuations.…”

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“…68, 69 Al considerar los efectos secundarios asociado a los AD (como somnolencia, ortostatismo, alucinaciones y desordenes en el control de los impulsos), hoy en día se ha tomado una postura moderada, en donde se reconoce que existe un lugar tanto para la levodopa (aún el antiparkinsónico más potente) como para los AD en el tratamiento de la EP.…”