Treatment options in the modern management of Parkinson Disease

Dopamine replacement therapy with levodopa has been the mainstay of symptomatic treatment of Parkinson disease (PD) for almost 40 years. While this drug remains the gold standard, several additional dopaminergic drugs have been introduced to provide alternatives for patients with PD. Practical challenges in the management of PD include determining the point at which drug therapy should begin and with what, the sequence and combination of drugs required as the disease progresses, and the place for parenteral therapy and surgery in advanced disease. Although levodopa offers effective symptom relief at all stages, its risk of inducing motor complications has led many to advocate alternative drugs for initiation in suitable patients. Dopamine agonists and monoamine oxidase (MAO) B inhibitors offer effective relief of the motor features of PD in early and more advanced disease and are associated with a low risk for motor complications. However, they are not as potent as levodopa. Parenteral dopamine agonist or levodopa delivery offers a useful intermediate or alternative to surgery.