Medication Strategies in Early Stages Disease


Common Dopaminergic Medicines in early disease

Carbidopa/Levodopa (Sinemet)
Dopaminergic agonists

     – Ropinirole (Requip)
     – Pramipexole (Mirapex)
     – Rotigitine (Neupro)
MAO B Inhibitors
     – Rasagiline (Azilect)
     – Selegeline (Eldepryl)

Medication Strategy in Early Disease

Note: The following is an excerpt from Alter The Course. Newly Diagnosed Parkinson’s disease by Sierra Farris, PAC and Monique L. Giroux, MD.

Levodopa is the most effective medicine for movement and has the lowest side effect profile. So why is this medicine so feared and misunderstood? Initially levodopa treats motor symptoms smoothly throughout the day. This changes with the emergence of on-off fluctuations as disease progresses and dopamine nerve cells degenerate. This first appears as a wearing off of medicine benefit before the next dose, a phenomenon called end of dose wearing off. Increase in medication strength, number of doses or use of additional medicines are then used to reduce off time. Dyskinesia (uncontrollable involuntary movements) can emerge as medications are increased or added. Levodopa has a greater risk of these problems due, in part, to the short half-life of this medicine in your bloodstream.

Longer acting medicines such as rasagiline and dopaminergic agonists when used alone at typical doses do not cause dyskinesia. So, the decision is simple- avoid levodopa…
Herein lies the paradox. Dopamine agonists have a higher risk of serious side effects such as confusion, hallucinations, dizziness, leg swelling and impulsivity control -limiting the dose that is tolerated and even their use altogether in patients with higher risk of these problems. Rasagiline has a lower side effect risk but is often not strong enough to fully treat movement symptoms as disease progresses. So, treatment must be customized…

Levodopa may be the best first medicine when side effect risk is high such as older individuals, people on many other medicines, with other significant medical problems affecting health or those with more severe movement problems. A levodopa conservative strategy can be used in younger people with less risk; beginning with agonists or rasagiline first and adding levodopa over the years when symptoms warrant. (In general, levodopa should be considered once significant balance, speech and swallowing problems emerge.)

Treatment Decisions

Begin Levodopa
  • Older patients
  • High side effect risk- confusion, multiple medical problems, many other medicines, other brain related problems or risks
  • Significant motor symptoms or occupation requiring high level of control
Begin Agonist
  • Younger patients
  • Patients with lower side effect risk
  • Adequate symptom control without troublesome side effects
Begin Rasagiline (Azilect)
  • Milder symptoms
  • Higher side effect risk
  • Desire once daily medicine
  • Interest in potential disease/symptom modifying effect