NICE Clinical Guideline 35 (Issued June 2006) on Parkinson's disease (PD) makes a number of recommendations. Key points on the management of PD include:
1. There is no consistently reliable test that can distinguish PD from other conditions that have similar clinical presentations. This diagnosis is primarily clinical, based on a history and examination.
2. Parkinsonism can also be caused by drugs, and conditions that are less common than PD. PD should be suspected in people presenting with tremor, stiffness, slowness, balance problems and/or gait disorders.
3. People with suspected PD should be referred quickly and untreated to a specialist with expertise in the differential diagnosis of this condition.
4. All people with PD who drive should be advised to inform the Driver and Vehicle Licensing Agency and their car insurer of their condition at the time of diagnosis.
5. It is not possible to identify a universal first-choice drug therapy for either early PD (ie people who have developed functional disability and require symptomatic therapy) or for adjuvant drug therapy for later PD (people on levodopa who have developed motor complications).
6. Generally, drug options that may be used for symptomatic treatment in early PD include levodopa, dopamine agonists or MAO-B inhibitors.
7. Generally, drug options that may be used as adjuvant therapy to reduce motor complications in later PD include dopamine agonists, MAO-B inhibitors, or COMT inhibitors.
8. When dopamine agonists are used, the non-ergot-derived agonists (pramipexole, ropinirole) should be preferred in most cases.
9. The EMEA has reviewed the safety profile of these drugs and has suggested that prescribing information is introduced to reduce the risk of fibrotic reactions. This includes the following advice: Ergot-derived dopamine agonists should not be taken by patients who have had fibrosis in the heart, lungs or abdomen. The absence of fibrosis in the heart should be verified before treatment is started. Patients should be monitored for the signs of fibrosis in the heart and elsewhere in the body throughout treatment, using blood tests or chest X-rays as appropriate. To reduce the risk of cardiac fibrosis, patients should be prescribed a daily maximum of 3 mg pergolide or cabergoline, or 30 mg bromocriptine. Many patients have been switched to alternative therapies, but if a patient decides in conjunction with their clinician to remain on their therapy, they will need to be closely monitored.
10. Be aware that the strength of pramipexole may sometimes be expressed in terms of base or sometimes in terms of salt.
11. As regards the MAO-B inhibitor selegiline, the BNF suggests that 10 mg selegiline by standard tablet formulation is similar to 1.25 mg of ZelaparR (tablet for dissolving on the tongue).
12. As regards the COMT inhibitors, if using entacapone and there are concerns over poor concordance, the triple therapy combination preparation (StalevoR contains levodopa, carbidopa and entacapone) may be offered. Tolcapone is used only if entacapone fails due to lack of efficacy or side effects. Tolcapone is prescribed by the specialist and requires liver function tests every two weeks during first year of therapy, and thereafter in accordance with the Summary of Product Characteristics.
13. Amantadine may be used to reduce dyskinesia in people with later PD.
14. For patients requiring apomorphine (which may be used to reduce off time in people with PD with severe motor complications), therapy should be initiated in hospital and titrated to an appropriate dose before discharge back into the community.
15. Antiparkinsonian medication should not be withdrawn abruptly or allowed to fail suddenly due to poor absorption (eg gastroenteritis, abdominal surgery) to avoid the potential for acute akinesia or neuroleptic malignant syndrome.
16. The practice of withdrawing patients from their antiparkinsonian drugs ('drug holidays') should not be undertaken because of the risk of neuroleptic malignant syndrome.
17. In view of the risks of sudden changes in antiparkinsonian medication, people with PD who are admitted to hospital or care homes should have their medication given at the appropriate times (which may mean allowing self-medication), and adjusted by, or only after discussion with, a specialist in the management of PD.
18. Clinicians should be aware of dopamine dysregulation syndrome (an uncommon disorder in which misuse of dopaminergic medication is associated with behaviours such as hypersexuality, pathological gambling and stereotypic motor acts). This syndrome may be difficult to manage.
19. Typical antipsychotic drugs (such as phenothiazines and butyrophenones) should not be used in people with PD who have mental health problems because they exacerbate the motor features of the condition.