Dopaminergic Therapy for Motor Symptoms in Early Parkinson Disease Practice Guideline Summary A Report of the AAN Guideline Subcommittee

Background and Objectives To review the current evidence on the options available for initiating dopaminergic treatment of motor symptoms in early-stage Parkinson disease and provide recommendations to clinicians. Methods A multidisciplinary panel developed practice recommendations, integrating findings from a systematic review and following an Institute of Medicine-compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence. Results Initial treatment with levodopa provides superior motor benefit compared to treatment with dopamine agonists, whereas levodopa is more likely than dopamine agonists to cause dyskinesia. The comparison of different formulations of dopamine agonists yielded little evidence that any one formulation or method of administration is superior. Long-acting forms of levodopa and levodopa with entacapone do not appear to differ in efficacy from immediate-release levodopa for motor symptoms in early disease. There is a higher risk of impulse control disorders associated with the use of dopamine agonists than levodopa. Recommendations on initial therapy for motor symptoms are provided to assist the clinician and patient in choosing between treatment options and to guide counseling, prescribing, and monitoring of efficacy and safety. Glossary AAN = American Academy of Neurology; AE = adverse event; CI = confidence interval; COI = conflict of interest; COMT = catechol-O-methyltransferase; CR = controlled-release; DA = dopamine agonist; DAWS = dopamine agonist withdrawal syndrome; EDS = excessive daytime sleepiness; ER = extended-release; ESS = Epworth Sleepiness Scale; GS = Guideline Subcommittee; ICD = impulse control disorder; IR = immediate-release; MAO-B = monoamine oxidase type B; MCID = minimal clinically important difference; PD = Parkinson disease; QUIP = Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease; RD = risk difference; RMD = raw mean difference; SSRI = selective serotonin reuptake inhibitor; UPDRS = Unified Parkinson's Disease Rating Scale.

Automated summary

The review found that initial treatment with levodopa provides better motor benefits compared to dopamine agonists, but is also more likely to cause motor complications. There was little evidence to suggest that any particular formulation or method of administration of dopamine agonists is superior. Long-acting forms of levodopa and combination formulations with entacapone do not appear to differ in efficacy from immediate-release levodopa for early disease motor symptoms. Patients using dopamine agonists may have a higher risk of impulse control disorders compared to those using levodopa.