Initiating therapy for Parkinson's disease.
Accurate diagnosis and individualized assessment of the risks and benefits of available antiparkinsonian medications should guide initiation of treatment for patients with early Parkinson's disease (PD). In general, the goals of treatment for younger patients (less than age 60 years) are control of impairing symptoms, sparing of levodopa to minimize long-term complications, and consideration of neuroprotection. The primary initial medication choices for patients under age 50 years include selegiline, amantadine, and anticholinergic agents. Patients in their fifties may require a dopamine agonist in addition to or instead of selegiline to achieve adequate symptom control. If the desired response is still not achieved, sustained-release carbidopa-levodopa should be added, followed by adjunctive amantadine or anticholinergic therapy. For older patients (60 years and over), improvement of functional impairment is the primary goal. For these patients, a special concern is to avoid inducing or exacerbating cognitive impairment. Sustained-release carbidopa-levodopa is considered first-line treatment for these patients. Inadequate response can be handled by a trial of immediate-release carbidopa-levodopa and then addition of a dopamine agonist when maximum levodopa doses are reached. Anticholinergic agents, amantadine, and selegiline should be avoided because of their CNS effects.
Silver
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Scripps Memorial Hospital, La Jolla, CA, USA.
Ruggieri
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D000203:Activities of Daily Living / Q000145:classification; D000328:Adult; D000368:Aged; D000547:Amantadine / Q000008:administration & dosage / Q000009:adverse effects; D000978:Antiparkinson Agents / Q000008:administration & dosage* / Q000009:adverse effects; D002230:Carbidopa / Q000008:administration & dosage / Q000009:adverse effects; D018680:Cholinergic Antagonists / Q000008:administration & dosage / Q000009:adverse effects; D003692:Delayed-Action Preparations; D018491:Dopamine Agonists / Q000008:administration & dosage / Q000009:adverse effects; D004338:Drug Combinations; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007980:Levodopa / Q000008:administration & dosage / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000187:drug effects; D010300:Parkinson Disease / Q000175:diagnosis / Q000188:drug therapy*; D012642:Selegiline / Q000008:administration & dosage / Q000009:adverse effects
D000978:Antiparkinson Agents; D018680:Cholinergic Antagonists; D003692:Delayed-Action Preparations; D018491:Dopamine Agonists; D004338:Drug Combinations; C009265:carbidopa, levodopa drug combination; D012642:Selegiline; D007980:Levodopa; D000547:Amantadine; D002230:Carbidopa