Treatment of Parkinson’s Disease

A.

Aerobic exercise may be neuroprotective, and should be recommended for all Parkinson disease (PD) patients.

Cognitively intact patients under age 65 years can try a monoamine oxidase type B inhibitor (MAOBI) or a dopamine agonist (DA) for the management of mild rigidity, bradykinesia, and gait changes ( Table 85.1 ). MAOBIs tend to be well tolerated but can cause hypertension and nonspecific dizziness, and selegiline can cause insomnia; they also can cause serotonin syndrome when used in combination with other serotoninergic medications. MAOBIs are relatively weak symptomatic medications, have a narrow dosing range, and are rarely used as monotherapy. Oral ropinirole and pramipexole, and transdermal rotigotine, are the most commonly used DAs. Side effects include hypersomnolence, leg edema, compulsivity, hypotension, and psychosis.

Table 85.1

Dosing and Titration of Medications for Parkinson Disease

Medication	Starting dose	Titration	Max dose
MAOBIs
Rasagiline	0.5 mg daily	Increase to 1 mg daily in 2 weeks	1 mg daily
Selegiline	5 mg daily	Increase to 5 mg bid after 2 weeks	5 mg twice daily
Safinamide	50 mg daily	Increase to 100 mg daily after 2 weeks	100 mg daily
Dopamine Agonists
Ropinirole	ER: 2 mg daily IR: 0.25 mg tid	ER: Increase by 2 mg every week IR: increase by 0.25 mg tid increments weekly	24 mg total daily dose
Pramipexole	ER: 0.375 mg daily IR: 0.125 mg tid	ER: increase by 0.375 mg every week IR: Increase by 0.125 mg tid increments weekly	4.5 mg total daily dose
Rotigotine	2 mg patch, apply daily	Increase by 2 mg patch every week	8 mg patch
Apomorphine	0.2 mL (2 mg) SC tid prn	May increase by 0.1 mL (1 mg) per dose every 3 days until single dose effectively rescues OFF period	Max single dose 0.6 mL (6 mg) Do not exceed 2 mL (20 mg) in a single day
Carbidopa/levodopa
	IR: 25/100 mg daily ER: 25/100 mg daily	Increase 1/2 tablet weekly for IR formulations; Increase 1 tablet weekly for ER formulations	Limited by side effects
Other
Amantadine	IR: 100 mg daily ER: 137 mg qhs	IR: Increase by 100 mg each week ER: increase to 274 mg qhs after 1 week	IR: 100 mg tid ER: 274 mg qhs
Trihexyphenidyl	0.5 mg daily	Add 0.5 mg weekly in bid or tid manner	4 mg tid Limited by side effects
Antipsychotics
Quetiapine	25 mg qhs	Increase by 25 mg weekly	300 mg daily
Pimavanserin	34 mg daily	None	34 mg daily
Clozapine	25 mg daily	Increase by 25 mg weekly	450 mg bid