KISS: Parkinson's Disease

NO PHARMACEUTICAL INFLUENCE
NO PHARMACEUTICAL INFLUENCE
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Based on NICE 2019, NG127 & NICE July 2017 and BMJ 2017;358;j1951

Diagnosis:

Non-pharmacological management:

  • Exercise - physical activity has been shown to be very important in reducing motor and non-motor symptoms; consider referring to physio especially if balance or motor problems.
  • Consider referral to Occupational Therapy if difficulty with activities of daily living & to Speech & Language therapy if problems with communication, swallowing or saliva.
  • Patient information and support: lots of good information from Parkinson’s UK.

Drug treatment of motor symptoms:

  • All drugs are for symptomatic benefit and none influence the long-term progression.
  • Initiation and alteration of all drugs should be done under specialist supervision.
  • First-line drugs: 
    • Levodopa  - better for motor symptoms with fewer adverse effects but higher long-term motor complications.
    • Dopamine agonists (non-ergot derived e.g. pramipexole, ropinirole) - less good for motor symptoms but fewer motor complications, but higher adverse effects.
    • MAO-B inhibitors - less good for motor symptoms but fewer motor complications, but higher adverse effects).
  • Adjuvant therapy: consider adding dopamine agonist, MAO-B inhibitor or COMT inhibitor to levodopa if dyskinesia or motor fluctuations despite optimal levodopa therapy.
  • Impulse control disorders (e.g. hypersexuality, gambling, binge eating) can occur with any dopamineric therapy, but particularly dopamine agonists; warn patients and family about this potential complication as can be distressing.
    • If it occurs seek specialist advice, but we should not alter/stop medications without advice - medications usually need to be slowly reduced due to risk of dopamine withdrawal.

Non-motor symptom treatment (review potential causative/contributory drugs in all cases):

  • Day time sleepiness, particularly associated with dopamine agonists; consider modafinil.
  • Rapid eye movement sleep disorder - consider clonazepam or melatonin.
  • Orthostatic hypotension: meds review important; consider midodrine or fludrocortisone.
  • Depression (CKS 2018) - can be difficult to diagnose as features may be wrongly attributed to the PD; consider CBT; best evidence for TCAs but use may be limited by side effects (cognitive impairment and falls) so SSRIs may be more appropriate.
  • Psychosis: don’t treat if well tolerated; consider quetiapine or clozapine (specialist only).
  • Dementia: consider cholinesterase inhibitor or memantine.
  • Drooling: refer to speech & language therapy or consider glycopyrronium bromide.

Palliative care - consider referring at any stage to consider end of life care.

Published on 29th January 2020

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