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  • Image not available. Thoughtful consideration of selection of initial therapy, management of drug dosing, and use of adjunctive therapies throughout the course of idiopathic Parkinson’s disease (PD) is necessary to optimize long-term therapeutic outcomes and minimize adverse effects.
  • Image not available. The optimal time to start drug therapy in PD varies, but in general, treatment should be initiated when the disease begins to interfere with activities of daily living, employment, or quality of life.
  • Image not available. Surgery is reserved for patients who require additional symptomatic relief or control of motor complications despite receiving medically optimized therapy.
  • Image not available. Anticholinergic medication is useful for mild tremor-predominant PD but should be used with caution in the elderly and in those with preexisting cognitive difficulties.
  • Image not available. As monotherapy, amantadine and monoamine oxidase type B (MAO-B) inhibitors provide benefits in early PD, but the symptomatic effect is less than that of dopamine agonists and carbidopa/levodopa (L-dopa).
  • Image not available. Carbidopa/L-dopa is the most effective medication for symptomatic treatment, and eventually all patients with PD will require it.
  • Image not available. Most carbidopa/L-dopa–treated patients will develop motor complications (e.g., fluctuations and dyskinesias).
  • Image not available. MAO-B inhibitors and catechol-O-methyl-transferase inhibitors attenuate motor fluctuations in carbidopa/L-dopa–treated patients.
  • Image not available. Dopamine agonists are effective and, compared to L-dopa, associated with less risk of developing motor complications but more risk to cause psychiatric symptoms, such as hallucinations and impulse control disorders.

On completion of this chapter, the reader will be able to:

  1. Discuss the epidemiology and etiology of idiopathic Parkinson’s disease (PD).

  2. Explain the basic pathophysiologic mechanisms responsible for the motor features of PD.

  3. List drugs that can exacerbate PD.

  4. Describe the cardinal motor features and clinical presentation of PD.

  5. List other conditions that may have motor features similar to PD.

  6. Recommend an initial treatment plan for a patient with PD based on patient-specific factors.

  7. Describe the pharmacology, clinical effects, and safety of anticholinergic drugs for the management of PD.

  8. Describe the pharmacology, clinical effects, and safety of amantadine for the management of PD.

  9. Describe the pharmacology, clinical effects, and safety of levodopa and peripheral decarboxylase inhibitors for the management of PD.

  10. Describe the pharmacology, clinical effects, and safety of dopamine agonists for the management of PD.

  11. Describe the pharmacology, clinical effects, and safety of catechol-O-methyltransferase (COMT) inhibitors for the management of PD.

  12. Describe the pharmacology, clinical effects, and safety of monoamine oxidase (MAO-B) inhibitors for the management of PD.

  13. Recognize the type of levodopa motor complication a patient is experiencing based on history and symptoms.

  14. Develop a treatment plan for a patient experiencing levodopa-associated motor complications.

  15. Develop a treatment plan for a patient with PD who is experiencing hallucinations and psychosis.

The presence of tremor at rest, rigidity, bradykinesia, and postural instability (instability of balance) are considered the hallmark motor features of idiopathic Parkinson’s disease (PD). These clinical features of PD were adeptly described in 1817 by James Parkinson.1

Up to 1 million individuals in the United States have PD. ...

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