Treatment Decision Making

Early Disease

The central questions in commencing treatment of PD are when to begin, and with what agent(s).

Potential Neuroprotection

If and when clearly neuroprotective agents are identified, they will obviously become the first treatments offered, and will be started as early as possible. As of mid-2004, no agent has been definitively shown to offer neuroprotection. Selegiline has a mild symptomatic effect, and is often used early for this in combination with its equivocal and much debated effects on slowing disease progression. Coenzyme Q10, available over the counter, is also used early. Its use is based on a single trial whose results suggested a possibly mild neuroprotective effect. Most PD experts believe the results of this trial are too preliminary and not compelling enough to change early treatment practices without repeating the study and duplicating the results.

Commencing Symptomatic Therapy

The decision of when to begin symptomatic therapy is an individual one made between patient and physician. Factors include:

• Degree of functional impairment
• Effect of symptoms on employment
• Patient attitudes towards medications

A patient who is fully educated regarding the benefits and limitations of therapy can be a full partner in the decision-making process. This obvious benefit is especially important in PD treatment, since treatment must be reevaluated and adjusted so often during the course of the disease, based on the changing condition of the patient and the response to previous therapy. It is in the interest of both patient and physician to develop such a partnership from the very beginning.

Initial Treatment Options

The choice of initial treatment is strongly influenced by patient age and condition. Levodopa is the usual treatment of choice in the elderly patient, because of its lower risk for psychiatric complications compared to dopamine agonists. A Dopamine agonists may be preferable in the younger patient, who is likely to be more tolerant of its side effects, and for whom delaying motor complications is an important goal, given the longer treatment horizon. Selegiline, amantadine, or an anticholinergic drug may also be appropriate initial treatment for mild symptoms, provided the side effects can be tolerated.

Depression and anxiety may also be early debilitating symptoms, and therefore may become the object of initial therapy.