Practice parameter: Initiation of treatment for Parkinson’s disease: An evidence-based review [RETIRED]

Abstract

Abstract-In 1993, the last AAN Practice Parameter on medical treatment of Parkinson's disease (PD) concluded that levodopa was the most effective drug for management of this disorder. Since then, a number of new compounds including non-ergot dopamine agonists (DA) and sustained-release levodopa have been released and studied. Thus, the issue of treatment in de novo PD patients warrants reexamination. Specific questions include: 1) does selegiline offer neuroprotection; 2) what is the best agent with which to initiate symptomatic treatment in de novo PD; and 3) is there a benefit of sustained release levodopa over immediate-release levodopa? Using evidence-based principles, a literature review using MEDLINE, EMBASE, and the Cochrane Library was performed to identify all human trials in de novo PD between 1966 and 1999. Only articles that fulfilled class I or class II evidence were included. Based on this review, the authors conclude: 1) Selegiline has very mild symptomatic benefit (level A, class II evidence) with no evidence for neuroprotective benefit (level U, class II evidence). 2) For PD patients requiring initiation of symptomatic therapy, either levodopa or a DA can be used (level A, class I and class II evidence). Levodopa provides superior motor benefit but is associated with a higher risk of dyskinesia. 3) No evidence was found that initiating treatment with sustained-release levodopa provides an advantage over immediate-release levodopa (level B, class II evidence).

Physical activity and behaviour in dementia

“…A total of 27 studies met our inclusion criteria for this review. In order to evaluate the studies on their methodological quality, we applied criteria that have been used in pharmacological treatment trials (Miyasaki, Martin, Suchowersky, Weiner, & Lang, 2002). These criteria classify intervention studies into three categories, broadly defined as:…”

Parkinson's Disease Therapeutics: New Developments and Challenges Since the Introduction of Levodopa

“…Since then, LD is once again recommended as a therapeutic intervention to be used early in the course of the disease (Obeso and Schapira, 2009;Schapira, 2009a, c;Schapira et al, 2009;Sethi, 2010), a recommendation that is supported by the American Academy of Neurology Practice Guidelines (Miyasaki et al, 2002). Currently, LD, oral dopamine receptor agonists, and MAO B inhibitors are approved by the Federal Drug Administration (FDA) for use in early and advanced PD, while COMT inhibitors and the broad-spectrum injectable dopamine agonist, apomorphine, are approved only for fluctuating PD symptoms.…”

Current Status of Symptomatic Medical Therapy in Parkinson’s Disease

“…Practice guidelines from the American Academy of Neurology indicate that the evidence supports many options. 24,134 Several key adverse events received significant attention in recent years and can be summarized in the following manner: melanoma (along with other skin cancers) may occur at an increased rate in PD, but there is no evidence to connect it causally with LD. Modest elevations of homocysteine have been seen with LD, but the importance has yet to be determined.…”

“…A practice guideline published by the American Academy of Neurology has indicated that using LD as first-line therapy is an acceptable approach. 24 …”