GENERAL COMMENTS ON DRUG MANAGEMENT OF PATIENTS WITH PARKINSONISM
Parkinson’s disease generally follows a progressive course. Moreover, the benefits of levodopa therapy often diminish with time, and serious adverse effects may complicate long-term levodopa treatment. Nevertheless, dopaminergic therapy at a relatively early stage may be most effective in alleviating symptoms of parkinsonism and may also favorably affect the mortality rate due to the disease. Therefore, several strategies have evolved for optimizing dopaminergic therapy, as summarized in Figure 28–5. Symptomatic treatment of mild parkinsonism is probably best avoided until there is some degree of disability or until symptoms begin to have a significant impact on the patient’s lifestyle. When symptomatic treatment becomes neces-sary, a trial of rasagiline, amantadine, or an antimuscarinic drug (in young patients) may be worthwhile. With disease progression, dop-aminergic therapy becomes necessary. This can conveniently be initiated with a dopamine agonist, either alone or in combination with low-dose carbidopa-levodopa therapy. Alternatively, especially in older patients, a dopamine agonist can be omitted and the patient started immediately on carbidopa-levodopa. Physical therapy is helpful in improving mobility. In patients with severe parkinsonism and long-term complications of levodopa therapy such as the on-off phenomenon, a trial of treatment with a COMT inhibitor or rasa-giline may be helpful. Regulation of dietary protein intake may also improve response fluctuations. Deep brain stimulation is often helpful in patients who fail to respond adequately to these measures. Treating patients who are young or have mild parkinsonism with rasagiline may delay disease progression and merits consideration.