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Age-related Neurodegenerative Disease Parkinson’s Disease
Parkinson’s Disease Therapy – When to Start and What to Choose
a report by
Andrew J Lees
Director, Reta Lila Weston Institute of Neurological Studies, University College London, and
Professor of Neurology, National Hospital for Neurology and Neurosurgery
Parkinson’s disease (PD) is a neurodegenerative disorder that, at least in functional ability. Useful practice parameters are also available from
the early stages, is predominantly characterised by a loss of nigrostriatal the Quality Standards Subcommittee of the American Academy of
dopaminergic function, and the presence of bradykinesia is a sine qua Neurology (AAN).
2
non for diagnosis. As the disease progresses, additional non-motor
symptoms sometimes emerge. The natural history of the disorder varies Evidence-based reviews by the MDS also offer some guidance of when
markedly from patient to patient, and attempts to delineate clinical to initiate therapy, as do the European Federation of Neurological
subtypes have been made (tremor-dominant, axial and bulbar forms). Societies (EFNS) guidelines, although the EFNS document is not widely
Treatment decisions take into account individual disabilities and the used outside Europe. Other algorithms for the treatment and
patient’s age (biological and chronological), occupation and lifestyle. management of patients with PD have also been published, but these
Accurate diagnosis is an essential pre-requisite for providing advice on
prognosis and planning of disease management. Several assessment
The recognition of numerous non-motor
tools are available for providing semi-quantitative measures of disease
symptoms in even the early stages of
progression, including: the Unified Parkinson’s Disease Rating Scale
(UPDRS), the current gold standard for motor assessment; the Mini Parkinson’s disease has prompted the
Mental State Examination (cognitive); the Geriatric Depression Scale
Movement Disorders Society to revise
(GDS15); and the Parkinson’s Disease Questionnaire-39 (PDQ39) (quality
of life [QoL]). Staging of PD using the Hoehn and Yahr (H&R) scale has
the UPDRS scale to include non-motor
also proved to be a useful and simple marker of disease progression.
and quality of life elements.
The recognition of numerous non-motor symptoms in even the early
stages of PD has prompted the Movement Disorders Society (MDS) to can be criticised on the grounds of pharmaceutical industry
revise the UPDRS scale to include non-motor and QoL elements. sponsorship.
3,4
Ultimately, although some guidance for the initial
Professor Christopher Goetz from Rush University Medical Center in treatment of PD is available, the question of when to start treatment and
Chicago is chairing the study group, and a publication appeared in the with what drug remains largely a decision for the treating physician.
1,5
December 2008 issue of Movement Disorders.
The optimal time-frame for onset of therapy has remained
Timing of Treatment controversial since levodopa became routinely available in 1969. One
There are a number of guidelines regarding the optimal time-frame for view supports early treatment, exemplified by the substantial
onset of therapy and treatment choices for PD patients, but most of improvements observed in de novo patients treated with levodopa and
these are not supported by robust evidence-based literature. In the UK, reduced mortality.
6–9
It has even been suggested that early treatment
the National Institute of Clinical Excellence (NICE) has developed could offer some neuroprotection to active dopaminergic neurons and
recommendations for the management and pharmacotherapy of PD in facilitate compensatory neuroplasticity.
10
primary and secondary care.
1
The NICE guidelines recommend
pharmacotherapy once motor symptoms begin to impair the patient’s An opposing view developed throughout the 1980s and 1990s, when
concerns regarding levodopa neurotoxicity and levodopa-related
motor complications led to the adoption by many neurologists of a
Andrew J Lees is Director of the Reta Lila Weston Institute
of Neurological Studies at University College London, and
‘watch and wait’ strategy: delaying the onset of levodopa therapy until
a Professor of Neurology at the National Hospital for
symptoms substantially impaired a patient’s functional ability.
11,12
Neurology and Neurosurgery in London. He is Director of
More recently, proponents of early treatment have taken advantage of
the Queen Square Brain Bank for Neurological Disorders
and the Sara Koe PSP Research Centre. Professor Lees is the improved dykinesia profile of dopamine agonists, particularly for
also Associate Director of the UK Dementias and
young-onset PD patients. Recently, a study by Grosset et al. called for
Neurodegenerative Diseases Research Network and
Chairman of the Clinical Studies Group on Parkinson’s
a re-evaluation of the policy of delaying treatment in de novo PD
Disease. He is Past President of the Movement Disorders Society (MDS) and former patients. In this PD-Life study, Grosset et al. showed a trend towards
Co-Editor in Chief of the journal Movement Disorders.
improvement in self-reported health status scores after PD
E: alees@ion.ucl.ac.uk
pharmacotherapy was initiated. This first-time report was an
observational study of the effect of anti-PD drug treatment, such that
34 © TOUCH BRIEFINGS 2008
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