Parkinson’s disease: when to treat and how?

Recently I was asked by someone when should we treat a patient with Parkinson’s disease, early on in the disease course or later when the clinical symptoms are more florid? As you know Parkinson’s disease is a progressive neurodegenerative condition characterized by tremor (resting tremor of the limbs, see my post on tremors, rigidity (stiffness), bradykinesia (patients have less spontaneous movements) and a characteristic disturbance of gait and posture (patients walk stooped forward and their balance is off, making them more prone to falls).

As you can well imagine all these symptoms do not start off all at once. Infact the onset of Parkinson’s disease is quite insidious and generally asymmetrical. In its earliest stages, all the patient may have is a unilateral (one hand) tremor. Later as time goes by and the disease progresses the symptoms become more florid and the bardykinesia and disturbance of gait and posture appear.

So that brings us to the question of my post, just when do we start treating these patients? Should we treat them early or should we treat them in the later stages?

There is no good answer to this question. One concern which has been raised is that if you treat patients with Parkinson’s disease with levodopa/ syndopa (the combination is called Sinemet in The United States), early on in the disease course, the drug itself may hasten the progression of the disease (the thinking behind this is the concern that levodopa may increase the breakdown of dopamine secreting cells in the basal ganglia).

On the other hand, there is some evidence to suggest that early treatment is better because it prevents the compensatory change in hardwiring which occur in the brain in the face of decreasing dopamine (some of the neurons such as that of the subthalamic nucleus become overactive in the face of decreasing dopamine secretion and this later on leads to more problems such as the on-off phenomena).

So what is the answer? I think a patient should be treated when he devlops symptoms that start bothering him or interfere with his functioning and activities of daily living. If that occurs early in the disease course, so be it, he warrants treatment. Nowdays apart from levodopa/syndopa (Sinemet) there are many other drugs which can be used to treat the disease especially in the early phases. These drugs ( dopamine agonists like Requip (Ropinirole) and Mirapex (Pramipexole) and selegine) are less stronger than levodopa/syndopa combination but are thought to have less “neurotoxicity” and hence are preferred to be used in the early stages of the disease.

Your doctor shall help you navigate these questions. Have a good weekend everyone. It is Saturday morning here in NYC as I pen this, I think I shall go for a run.

Personal Regards,

Nitin Sethi, MD

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