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Two questions central to the management of early Parkinson's disease are when to treat and with what to treat. When to treat remains controversial, with the available medications for Parkinson's disease showing no definite evidence of any disease-modifying effect despite some reports of improvements in quality of life in those treated early in the disease course.1 As for what drug to use in early Parkinson's disease, there is little available comparative evidence; practice varies enormously among neurologists and geriatricians, reflecting the inherent uncertainties of what constitutes the best treatment overall.
The three main classes of first-line treatment are L-dopa, dopamine agonists and monoamine oxidase-B inhibitors. Most specialists accept that L-dopa is the most effective for motor symptoms, all other things being equal, based upon two main factors:
L-dopa is favoured over dopamine agonists in patients with increasing biological age and/or associated co-morbidity.
L-dopa is favoured over both dopamine agonists and monoamine oxidase-B inhibitors in patients with severe motor symptoms.
‘Dopa-phobia’ leads many clinicians to avoid using L-dopa in young-onset Parkinson's disease in an attempt to delay the onset of motor fluctuations and dyskinesias. However, increasing recognition of the complications of dopamine agonists—including impulse-control disorders in up to 39% of patients2—has tempered enthusiasm for their use, especially in young-onset Parkinson's disease.
Guidelines from the UK's National Institute for Health and Care Excellence (NICE, 2006) and from the Scottish Intercollegiate Guidelines Network (SIGN, 2009) find no single ‘first line’ treatment has a consistent advantage over any other; however, there have been no large-scale randomised trials of all three therapies until now.
The results of the long-awaited early stage PD MED study (Lancet 2014) have now been published nearly 2 years after initial outline results were presented in late 2012 in Shanghai. This unusual delay led to a barrage (almost …
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