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Incorporating NICE Guidance NG71: Parkinson's disease in adults (July 2017)
It is important to eliminate the possibility of anti-dopaminergic drugs causing parkinsonian symptoms, for example prochlorperazine, metoclopramide, chlorpromazine, trifluoperazine, haloperidol, and less commonly, the newer atypical antipsychotics (e.g. risperidone).
If Parkinson's disease (PD) is suspected all patients regardless of age should be referred to a specialist untreated, for confirmation of the diagnosis and assessment. Refer to the following Clinical Referral Guidelines:
The diagnosis should be reviewed by the specialist at regular intervals (6-12 months)
The aim of treatment is to alleviate symptoms, and to restore or improve quality of life. At present no treatment has been proven to slow down the progression of the disease.
Decisions should be made after discussions between the patient, their carer and the clinician about the degree of disability and the pros and cons of starting drug therapy. Before starting treatment for patients with Parkinson's disease, discuss:
In general, start only one new class of medication at a time. Dose titration should always be gradual - antiparkinsonian medication should never be started or stopped suddenly. It may take up to 3 months on a therapeutic dose before the full symptomatic benefits become apparent.
Elderly: Antiparkinsonism drugs carry a special risk of inducing confusion in the elderly. It is particularly important to initiate treatment with low doses and to use small increments.
Successful long-term management requires multidisciplinary care and a team approach involving the General Practitioner, hospital specialist, district nurse and Parkinson's Disease Nurse Specialist (PDNS) together with the patient and their carer(s). The skills and services of the physiotherapist, speech and language therapist, occupational therapist, clinical psychologist and pharmacist are likely to be required at various stages of the disorder. Access to nutrition and dietetic services, skilled dental care and health information and educational services are also needed as part of the team.
Levodopa as monotherapy should be offered to patients in the early stages of Parkinson's disease whose motor symptoms impact their quality of life.
There may be individual patient specific reasons where monoamine oxidase B (MAO-B) inhibitors or dopamine agonists may be offered as an alternative 1st line treatment option in patients whose motor symptoms impact their quality of life.
When motor symptoms do not impact on a patient's quality of life in the early stages of Parkinson's disease a choice of dopamine agonists, levodopa or (MAO-B) inhibitors should be considered.
Some potential benefits and harms of dopamine agonists, levodopa and MAO B inhibitors are compared in the table below:
|Levodopa||Dopamine agonists||MAO-B inhibitors|
|Motor symptoms||More improvement in motor symptoms||Less improvement in motor symptoms||Less improvement in motor symptoms|
|Activities of daily||More improvement in activities of daily living||Less improvement in activities of daily living||Less improvement in activities of daily living|
|Motor complications||More motor complications||Fewer motor complications||Fewer motor complications|
|Adverse events (excessive sleepiness, hallucinations & impulse control disorders)||Fewer specified adverse events||More specified adverse events||Fewer specified adverse events|
Offer a choice of dopamine agonists, MAO-B inhibitors or catechol-O-methyl transferase (COMT) inhibitors as an adjunct to levodopa for people with Parkinson's disease who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy:
Some potential benefits and harms of dopamine agonists, MAO‑B inhibitors, COMT inhibitors and amantadine are compared in the table below:
|Dopamine agonists||MAO-B inhibitors||COMT inhibitors||Amantadine|
|Motor symptoms||Improvement in motor symptoms||Improvement in motor symptoms||Improvement in motor symptoms||No evidence of improvement in motor symptoms|
|Activities of daily living||Improvements in activities of daily living||Improvements in activities of daily living||Improvements in activities of daily living||No evidence of improvements in activities of daily living|
|Off-time||More off-time reduction||Off-time reduction||Off-time reduction||No studies reporting this outcome|
|Adverse events||Intermediate risk of adverse events||Fewer adverse events||More adverse events||No studies reporting this outcome|
|Hallucinations||Higher risk of hallucinations||Lower risk of hallucinations||Lower risk of hallucinations||No studies reporting this outcome|
Apomorphine is not considered suitable as first choice adjuvant treatment option.
Amantadine should be considered if dyskinesia is not adequately managed by modifying existing therapy.
It is recommended that advice is sought from Parkinson's disease specialists before initiating treatment for problems associated with Parkinson's disease.
After seeking advice from a healthcare professional with specialist expertise in Parkinson's disease, adjust medication to reduce the occurrence of daytime sleepiness. Patients with daytime sleepiness and/or sudden onset of sleep should be advised not to drive (and to inform the DVLA) and to think about any occupational hazards.
Depression occurs commonly in patients with Parkinson's disease and can easily be overlooked. No single class of antidepressant has been proven to be superior. Antidepressant therapies may exaggerate parkinsonian symptoms, as they can have extrapyramidal side effects. They are difficult to predict as they depend on dose, drug and individual susceptibility.
Offer speech and language therapy for people with Parkinson's disease who are experiencing problems with swallowing or saliva.
If this is ineffective, refer to specialist.
If a patient has developed dyskinesia and/or motor fluctuations, including medicines 'wearing off' seek advice from a healthcare professional with specialist expertise in Parkinson's disease before modifying therapy.
If dyskinesia is not adequately managed by modifying existing therapy, specialists may consider amantadine.
Do not offer anticholinergics to patients who have developed dyskinesia and/or motor fluctuations
Impulse disorders can develop in a person with Parkinson's disease who is on any dopaminergic therapy at any stage in the disease course. Patients are at an increased risk of developing impulse control disorders if they are on dopamine agonist therapy, have a history of previous impulsive behaviour or have a history of alcohol consumption and/or smoking.
There is an increased risk of impulse control disorders when taking dopamine agonist therapy at any stage in the disease course, but it can also develop while taking other dopaminergic therapies
Advice should be sought from a specialist before modifying dopaminergic therapy.
Patients and carers should be given written and oral information about risk of developing impulse control disorders, type of control disorders and who to contact
Domperidone is the antiemetic of choice in Parkinson's disease as it cannot easily cross the blood-brain barrier and cause additional motor disturbances. See section 4.6 Drugs used in nausea and vertigo.
Avoid metoclopramide and prochlorperazine in patients with Parkinson's disease.
Postural (orthostatic) hypotension may result from the disease and/or the treatment. Existing medications should be reviewed to address possible pharmacological causes, including:
If pharmacological causes cannot be addressed, NICE recommends midodrine (non-formulary) as a first line treatment (due to the availability of a licensed product). However local specialists indicate a preference for fludrocortisone (off-label use) as the first line treatment option, taking into account its safety profile. Midodrine tablets (Bramox®) are available at significantly increased cost; however there is a lack of evidence of clinical benefit of midodrine over fludrocortisone. Midodrine is reserved for use in patients for whom fludrocortisone is ineffective or not tolerated.
Psychosis occurs in around 20% of patients with Parkinson's disease and is usually due to medical treatments. Clinicians should ask about hallucinations or delusions at reviews.
Treatment is not necessary if the hallucinations and delusions are well tolerated by the person with Parkinson's disease and their family members and carers.
Seek advice from a healthcare professional with specialist expertise in Parkinson's disease before modifying therapy
Psychosis management requires careful step-wise adjustment of drug treatment and there is a trade-off between control of psychosis and reduced motor control.
Seek specialist advice for the management of other problems associated with Parkinson's disease such as: