Therapy goals
- Improvement of mobility
- Improvement/mitigation of tremor
- Improvement of the psychological and vegetative symptoms.
Therapy recommendations
Therapy recommendations of the German Society of Neurology.
Patient | Active ingredient groups | Active ingredients | |
<70 years,no significant comorbidities | First choice agent | Dopamine receptor agonists | Piribedil pramipexole ropinirole |
Non-ergoline dopamine agonists | Rotigotine | ||
Second choice agent | Ergoline dopamine agonists | Bromocriptine cabergoline α-dihydroergocriptine lisuride pergolide | |
Alternative for mild symptoms | MAO inhibitor (monoamine oxidase inhibitor). | RasagilineSelegiline | |
N-methyl-D-aspartate recptor antagonists (NMDA antagonists). | Amantadine* * | ||
> 70 yearsMultimorbidity | Means of first choice | Levodopa | L-dopa* |
Alternatively for mild symptoms | MAO inhibitor (monoamine oxidase inhibitor). | RasagilineSelegiline | |
N-methyl-D-aspartate recptor antagonists (NMDA antagonists). | Amantadine |
* The older the PD patient, the lower the risk of dyskinesia with L-dopa. * * Amantadine may be considered as second-line therapy for patients in early stages of idiopathic Parkinson’s syndrome IPS). (Expert Consensus)
Further references
- MAO-B inhibitors, dopamine agonists, or levodopa should be used in the symptomatic therapy of early stage idiopathic Parkinson’s disease (IPS). A (1++)The selection of the different substance classes should take into account the different effect sizes in terms of efficacy, side effects, age of the patient, comorbidities, psycho-social requirement profile. Expert consensus
- L-dopa:
- Has the strongest effect on akinesia (high-grade lack of movement to immobility), followed by rigor (rigidity; muscle stiffness) > tremor (shaking)
- First-line agent in elderly patients (> 70th LJ) or in multimorbid patients.
- Must always be combined with peripheral decarboxylase inhibitors (benserazide or carbidopa) to prevent levodopa from being converted to dopamine in the intestine immediately after administration
- Combination with dopamine agonists recommended.
- Toxicity: the LEAP study showed that early therapy with L-dopa does not carry additional risks.
- Dopamine agonists (see above ):
- Act most strongly on akinesia, followed by rigor > tremor.
- Monotherapy is method of first choice in young patients (< 70th LJ) without significant co-morbidities; combination with levodopa recommended if success is unsatisfactory
- Anticholinergics (biperiden, metixen, trihexyphenidyl): most effective in rigor and tremor; Cave! Not in elderly patients or in cognitively impaired individuals.
- COMT (catechol-O-methyl transferase) inhibitors: only in combination with L-dopa for “end-of-dose” fluctuations (L-dopa).
- MAO inhibitors (monoamine oxidase inhibitors): rasagiline, selegiline.
- Selegiline as a monotherapeutic agent in elderly and multimorbid patients with mild symptoms.
- N-methyl-D-aspartate recptor antagonists (NMDA antagonists): amantadine.
- Has the strongest effect on akinesia and rigor.
- Agent of choice in akinetic crisis
- First-line monotherapy for mild symptoms in young as well as elderly patients and multimorbidity.
- Loss of effect after a few months
- The use of psychotropics (psychoactive substances) in elderly patients is associated with increased mortality (mortality)
- Beta-blockers may be considered for symptomatic therapy of postoral tremor in selected patients with early idiopathic parkinsonism but should not be first-line agents. (Expert Consensus)
- When off-phases (phases when the antiparkinsonian drug has no effect) in IPS cannot be adequately controlled with oral medication, subcutaneous apomorphine injections are recommended; alternatively, intrajejunal levodopa/carbidopa infusion.
- See also under “Further therapy”.
New active ingredients
- Safinamide; mode of action: dual mechanism of action (MAO-B inhibitor and antiglutamatergic effect); indication: idiopathic Parkinson’s disease (IPS):
- Only in patients taking L-dopa.
- Avoiding an increase in L-dopa doses above 400 mg.
- Mild motor fluctuations
- Mild dyskinesias
- Possibly improvement of attention
- Wearing-Off
Parkinson’s disease and fatigue (tiredness) and anhedonia (inability to feel pleasure and joy)
Guideline recommendations:
- Methylphenidate or modafinil cannot be recommended for use in the symptom-based treatment of fatigue syndrome in IPS. (Expert consensus)
Parkinson’s disease and dementia or dementia of Lewy body type (PSYC3)
Guideline recommendations:
- Rivastigmine should be used in the treatment of cognitive symptoms in patients with Parkinson’s disease dementia (PDD). B (1++)
- Donepezil can be used in the treatment of cognitive symptoms in patients with PDD. This is an off-label use.
PDD and depression
Guideline recommendations:
- Tricyclic antidepressants should be used to treat depression in patients with idiopathic Parkinson’s disease (IPS). A (1++)
- Newer-generation antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and venlafaxine should be used to treat depression in patients with IPS. B (1++)
- Alternative therapies such as omega-3 fatty acids (DHA, EPA) can be used to treat depression in patients with IPS 0 (1+).
- Repetitive transcranial magnetic stimulation can be used to treat depression in patients with IPS 0 (1+).
- Psychotherapy should be used to treat depression in patients with IPS.
Parkinson’s disease and hypersalivation
Hypersalivation (sialorrhea or ptyalism; English “drooling”), the involuntary discharge of saliva above the lip margin, occurs in up to 75% of patients with idiopathic PD. In a randomized, double-blind, placebo-controlled study in a cross-over design, 10 patients were studied with incobotulinum toxin (100 units) versus NaCl 0.9%. One injection was given monthly into each of the parotid (20 units) and submandibular (30 units) glandula. Patients were examined monthly: no effect of incobotulinum toxin A on hypersalivation in IPS was demonstrated.
Parkinson’s disease and psychosis
Guideline recommendations:
- Clozapine should be used to treat psychosis in patients with idiopathic Parkinson’s disease IPS. A (1++)
- Quetiapine can be used to treat psychosis in patients with IPS. (Expert consensus)
- Olanzapine should not be used to treat psychosis in patients with IPS. A (1++)
- In patients with IPS psychosis and concomitant dementia, cholinesterase inhibitors are an alternative. (Expert consensus)
Parkinson’s disease and sleep disorders
Guideline recommendations:
- Nocturnal akinesia (high-grade lack of movement to immobility) and early morning dystonia (movement disorder manifested by involuntary contraction of muscles) should be treated with transdermal rotigotine or sustained-release ropinirole. (1+)
- Treatment of insomnia with sleep-through disturbance should be attempted with zopiclone. B (1+)