Parkinson disease
- Levodopa is the most effective motor-symptom therapy
- Dopamine agonist/MAO-B inhibitor for selected patients
- Adjust dosing for wearing-off/dyskinesia
- DBS or infusion therapy for advanced fluctuations
- Exercise is a core nonpharmacologic treatment
- Treat psychosis, orthostasis + cognition separately
Use at a glance
- Levodopa is the most effective motor-symptom therapy
Choosing treatment
- Dopamine agonist/MAO-B inhibitor for selected patients
- Adjust dosing for wearing-off/dyskinesia
Treatment options
- DBS or infusion therapy for advanced fluctuations
Other treatment options
- Exercise is a core nonpharmacologic treatment
- Treat psychosis, orthostasis + cognition separately
Key points
- No disease-modifying therapy exists
- Carbidopa/levodopa most effective for motor symptoms
- Dopamine agonists: less effective, fewer fluctuations/dyskinesia; monotherapy or adjunct
- Off-episode rescue: liquid or inhaled levodopa, SC/SL apomorphine
- Advanced fluctuations: add COMT inhibitor, MAO-B inhibitor, or istradefylline (no ↑ dyskinesia)
- Amantadine: early monotherapy or adjunct; ↓ levodopa dyskinesia. Anticholinergics for tremor/drooling, rarely used
- DBS if motor complications + intact cognition; exercise improves function, QoL; treat nonmotor symptoms
Nonpharmacologic therapies
- Deep brain stimulation
- Surgical ablation
- Focused ultrasound subthalamotomy
- Exercise therapy
- CBT
- ECT
- Enteral infusion pump
Pearls
- Extra carbidopa can relieve levodopa nausea
- Anticholinergics: avoid in elderly; never stop abruptly
- DBS doesn't help speech, balance, or gait freezing
- STN DBS spares more medication; GPi curbs dyskinesia more
- Cholinesterase inhibitors aid PD dementia but may worsen tremor
Self-check
- Which Parkinson symptoms need separate treatment?
Psychosis, orthostasis and cognition. - What treats advanced Parkinson fluctuations?
DBS or infusion therapy.
Drugs used for this (18)
All clinical uses · Open Parkinson disease in the interactive console ↗