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Overview: Management of Early Parkinson Disease

AMA Therapeutic Insights newsletter overview: March 2009

Access full program AMA Therapeutic Insights is a free, online CME program featuring the latest treatment guidelines and prescribing data for specific disease states.  The following is an overview of the March 2009 newsletter, "Management of Early Parkinson Disease." 

To view the full newsletter and prescribing information or to take the CME self-assessment, visit AMA Therapeutic Insights (free to both AMA members and non-members).

Parkinson disease is caused by the slow progressive loss of dopaminergic neurons in the substantia nigra, resulting in the cardinal motor symptoms of resting tremor, bradykinesia, rigidity, and in later stages, postural instability.  Although treatment often requires referral to a neurologist or movement disorder specialist, it is still important for the PCP to have an effective approach to diagnosis and early treatment of this movement disorder.  This CME program provides an overview of the evidence-based treatment of early Parkinson disease.

What agents are used in the early treatment of Parkinson Disease?
Most of the drugs currently available for Parkinson disease primarily act on the dopaminergic system. These drug classes include anticholinergics, NMDA antagonist (amantadine), MAO-B inhibitors, COMT inhibitors, dopamine receptor agonists, and dopamine precursors. The choice between drugs is based on a combination of factors including variables relating to the drug and to the patient.  Using patient claims data linking the diagnosis of Parkinson disease with the specific drugs used in its treatment, a picture of the relative use of the different classes of agents in a relatively young patient population with Parkinson disease is shown in the figure. 

Different classes of agents used in younger population
The patient population 45-54 years of age shows higher use of dopamine agonists while the 54-64 year old patient group shows a shift to greater use of dopamine agonist and levodopa, with a greater proportion on levodopa therapy.

Case Study 1
A 62-year-old right handed dentist presents to you with a complaint of intermittent tremor in his left hand. He first noticed some mild stiffness and slowness in his left hand about 1.5 years ago. He reports that with concentration he can suppress his tremor. He expresses concern that he might have Parkinson disease. On examination he has mild facial masking, an intermittent resting tremor on the left, as well as mild rigidity and bradykinesia in that hand. His gait is normal although he has decreased armswing on the left and his postural stability is good. Based on your examination and ruling out other causes for his symptoms, you make the initial diagnosis of idiopathic PD in this patient.

Your patient states that he has no difficulty performing any of his ADLs at home, and it takes him no longer to get ready in the morning than it did a year and half ago. However, he does indicate that he is having more difficulty performing certain procedures at work. It is for this reason that he is interested in initiating symptomatic therapy. What is your approach?

To view the full newsletter and receive CME credit, visit AMA Therapeutic Insights (available all physicians, not just AMA members).