Magazine article Drug Topics

New Parkinson's Guidelines Urge Shift in Treatment

Magazine article Drug Topics

New Parkinson's Guidelines Urge Shift in Treatment

Article excerpt

New treatment guidelines will, it is hoped, settle an ongoing debate about whether the initial treatment for patients with Parkinson's disease (PD) should be levodopa or a dopamine agonist. Published as a supplement in the June issue of the journal Neurology, the evidence-based guidelines, developed by leading neurologists, now recommend using dopamine agonists as first-line monotherapy for treating early PD.

Dopamine agonists available in the United States to treat the nearly one million Americans affected with this chronic and progressive movement disorder include bromocriptine (Parlodel, Novartis), pergolide (Permax, Athena Neurosciences), pramipexole (Mirapex, Pharmacia Corp.), and ropinirole (Requip, GlaxoSmithKline).

At present, there are no curative therapies for PD, and management is symptomatic only. Levodopa has been the mainstay of treatment for PD for several decades. But longterm use of the agent is associated with motor complications.

"Eighty percent of people who take levodopa have complications from the drug-involuntary movements and fluctuating responses," said C. Warren Olanow, M.D., FRCPC. He is coauthor of the guidelines and chairman of the department of neurology at Mount Sinai School of Medicine.

So the question posed by William Koller, M.D., during a telephone press conference was, "Can we prevent or delay these motor complications and response fluctuations, because once they do occur, they are very difficult to treat?" Koller is director of the Division of Movement Disorders at the University of Miami and coauthor of the new guidelines. Studies conducted during the past two to three years have given us the answer to this question, responded Koller.

One of these significant studies was a five-year, double-blind, controlled study published in the May 2000 issue of the New England Journal of Medicine. This study showed that the early use of the dopamine agonist ropinirole significantly reduces the risk of dyskinesia in patients with PD. The overall incidence of dyskinesia at five years was 20% in the ropinirole group, as compared with 45% in the levodopa group.

"We used to think if dopamine agonists were used first, they would be good for several months only, and then you would have to add levodopa," observed Koller. The results from this study have changed that way of thinking. Half of the patients maintained symptom control on rop=ole monotherapy at three years, and one-third remained on monotherapy at five years.

Koller did stress that for elderly patients (>70 years) and for patients with cognitive impairment, levodopa plus a decarboxylase inhibitor (carbidopa) may be a better choice. …

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