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Treatment of Parkinson’s Disease

Treatment of Parkinson’s Disease. Thomas L. Davis, M.D. Associate Professor of Neurology Vanderbilt School of Medicine. Treatment of PD Question Diagnosis. Four cardinal features PD (parkinsonism = 2/4 features Rest tremor Bradykinesia Rigidity Loss of postural reflexes

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Treatment of Parkinson’s Disease

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  1. Treatment of Parkinson’s Disease Thomas L. Davis, M.D. Associate Professor of Neurology Vanderbilt School of Medicine

  2. Treatment of PDQuestion Diagnosis • Four cardinal features PD (parkinsonism = 2/4 features • Rest tremor • Bradykinesia • Rigidity • Loss of postural reflexes • Drug Induced Parkinsonism – treatment is to stop the offending agent

  3. Treatment of PDNeuroprotection • No proven treatments – this is the subject of a large NIH trial – potential agents under study include: • Minocycline • Creatine • CoQ10 • GPi- 1485

  4. Treatment Of PDGeneral Strategy • Continuous dopaminergic stimulation – may avoid long term motor fluctuations • Small frequent doses • Longer acting agents (dopamine agonists, sustained release prep of L-DOPA) • Delay metabolism of L-DOPA or dopamine (COMT inhibitors, MAO inhibitors)

  5. Treatment of PDL-DOPA • Mainstay of therapy – single most effect agent • Increases lifespan in PD pts. • Many pharmacokinetic challenges • Now used more sparing than in the past to minimize motor fluctuations.

  6. Treatment of PD Dopamine agonist • Longer duration than L-DOPA • Less effective than L-DOPA • Less tolerated then L-DOPA • Frequently used early in disease and as an adjunct to L-DOPA

  7. Treatment of PDCOMT Inhibition • Blocks conversion of L-DOPA to inactive 3-O-methyldopa in the gut • Prolongs the duration of effect of L-DOPA • Increases AUC of L-DOPA without effecting Tmax

  8. Treatment of PDOther Agents • Selegiline / Rasagiline – specific MAO-B inhibitor – prolongs the duration of L-DOPA by blocking the metabolism of dopamine • Amantadine – many minor actions including glutamate antagonist – has mild antiparkinsonian effect and may block dyskinesia

  9. It is legal to prescribe a non- approved medication for your patients ? • True • False

  10. Treatment of PDNon motor symptoms • Cognitive difficulty • Depression • Constipation • Sexual dysfunction • Sleep disorders

  11. Treatment of PDDrug AE’s • Nausea – carbidopa / domperidone • Nightmares / Hallucinations – atypical neuroleptic – use with caution • Orthostatic hypotension – water, salt, • Impulse control disorder - atypical neuroleptic

  12. Treatment of PDDeep Brain Stimulation • Use to treat PD complicated by severe motor fluctuations not responsive to medications. • In general, it does not improve sx that L-DOPA does not.

  13. New Therapies for Parkinson’s Disease • Apomorphine – rapidly acting, brief duration SQ dopamine agonist for unpredictable off periods. • Rapidly dissolvable L-DOPA • Transdermal dopamine agonist

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