Parkinson's Disease: Management

Key points

• Diagnosis and initiation of treatment should be by a specialist with expertise in movement disorders (NICE NG71).
• Motor symptoms affecting quality of life → offer LEVODOPA first-line. Motor symptoms not yet affecting quality of life → consider a choice of a non-ergot dopamine agonist, levodopa, or a MAO-B inhibitor.
• Levodopa gives more improvement in motor symptoms and activities of daily living, but more motor complications (dyskinesia, wearing-off) · dopamine agonists cause fewer motor complications but more adverse events including impulse control disorders.
• Do NOT offer ergot-derived dopamine agonists first-line — follow MHRA guidance on their warnings and contraindications (fibrotic reactions).
• When starting any dopaminergic therapy, give oral AND written information and record the discussion: impulse control disorders (pathological gambling, hypersexuality, binge eating — higher risk with dopamine agonists, but possible with all dopaminergic drugs) · excessive daytime sleepiness and sudden onset of sleep · psychotic symptoms (hallucinations, delusions).
• Excessive daytime sleepiness: advise not to drive and to inform the DVLA · exclude other causes before considering modafinil, which is contraindicated in pregnancy or when planning pregnancy · if a problematic impulse control disorder develops, seek specialist advice and reduce the dopamine agonist gradually.
• Motor fluctuations or dyskinesia: add a dopamine agonist, MAO-B inhibitor or COMT inhibitor as an adjunct to levodopa · never stop levodopa abruptly (risk of acute akinesia and neuroleptic malignant-like syndrome) · inpatients should get their levodopa within 30 minutes of the prescribed time.

Decision points in this pathway

• Do motor symptoms affect quality of life?
• Problematic impulse control disorder develops?
• Motor fluctuations or dyskinesia on levodopa?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.