4. A patient is suffering from Parkinson’s disease. Suggest the modern technique
to treat this disease.
Answers
There are many guidelines available concerning the treatment of Parkinson's disease. Most of these advocate treating young-onset patients with a dopamine agonist and older patients with levodopa. The rationale behind this recommendation has its origins in the side effects associated with each of these drug classes: whilst levodopa leads to dyskinesia, which may not be relevant for patients with a limited life-expectancy, dopamine agonists have a much longer plasma half life which probably leads to more continuous dopamine receptor stimulation and thus decreases the occurrence and severity of dyskinesia. However, the side effects associated with the use of dopamine agonists, such as sleepiness, orthostatic problems, hallucinations and impulse control disorders are a drawback. In this overview, the hypothesis will be put forward that perhaps such a strict distinction is no longer needed. A new idea may be the early combination of levodopa with a dopamine agonist which would provide good clinical efficacy and, because of the relatively low doses involved, would reduce the side effects associated with both substances. MAO-B inhibitors may be a good option for early treatment and especially for patients who experience first motor fluctuations. Similarly, and particularly if a wearing-off symptom is present, COMT inhibitors smoothen and prolong the action of levodopa. More invasive escalation therapy comes into play when patients reach the advanced stages with problems of insufficient motor control, such as bradykinesia, rigidity and resting tremor, combined with on-time dyskinesia. The use of all oral and invasive treatment has to be individualized to gain a good motor and non-motor control and especially a good quality of life.
Treatment Options in the Modern Management of Parkinson Disease
Dopamine replacement therapy with levodopa has been the mainstay of symptomatic treatment of Parkinson disease (PD) for almost 40 years. While this drug remains the “gold standard,” several additional dopaminergic drugs have been introduced to provide alternatives for patients with PD. Practical challenges in the management of PD include determining the point at which drug therapy should begin and with what, the sequence and combination of drugs required as the disease progresses, and the place for parenteral therapy and surgery in advanced disease. Although levodopa offers effective symptom relief at all stages, its risk of inducing motor complications has led many to advocate alternative drugs for initiation in suitable patients. Dopamine agonists and monoamine oxidase (MAO) B inhibitors offer effective relief of the motor features of PD in early and more advanced disease and are associated with a low risk for motor complications. However, they are not as potent as levodopa. Parenteral dopamine agonist or levodopa delivery offers a useful intermediate or alternative to surgery.
The introduction of levodopa for the treatment of PD has led to a significant improvement in both the quality of life and life expectancy of patients, although they continue to experience significant disability that increases as the disease progresses.1 Current treatments remain focused on the dopamine system. Two evidence-based reviews of PD treatment have recently been published and provide an excellent critical analysis of medical and surgical therapies.2,3 Given the range of potential treatments to offer a patient with PD, it is helpful to set these reviews in a pragmatic clinical context and consider how our practice should best reflect these advances to suit the patient in both the short- and long-term