Management of Parkinson’s disease

pharmaceutical-journal.com/article/ld/management-of-parkinsons-disease

An overview of the symptomatic management of Parkinson's disease.

Parkinson's disease

10 June 2022
By Anushka Dewan, Deborah Clark, Shelley Jones & Jasvir Bassan

Peer Reviewed

MRI brain scan of patient with Parkinson's disease

ZEPHYR / SCIENCE PHOTO LIBRARY

CPD module
After reading this article, test your knowledge by completing the CPD questions and receive
a certificate as a record of your learning.

After reading this article, you should be able to:

Explain the aetiology and signs and symptoms of Parkinson’s disease;

Understand the available management options for motor and non-motor symptoms;
List simple interventions pharmacists can perform to improve the quality of life of
people with Parkinson’s disease.

Parkinson’s disease (PD) is a chronic neurodegenerative disorder, first described in 1817 in

‘An essay on the shaking palsy’ by surgeon James Parkinson. It is caused by the loss of
dopamine-containing cells in the substantia nigra. Dopamine is critical to movement;
therefore, its loss leads to motor symptoms affecting movement​[1,2]​. However, as
understanding of PD increases, it is becoming clear that PD is not just a disorder of
movement, but is associated with significant non-motor symptoms too​[3,4]​.

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In the UK, 1 in 37 people are diagnosed with PD in their lifetime. Approximately 93% of
people with PD in the UK are aged 50–89 years​[5]​. The charity Parkinson’s UK estimates
that there are 145,000 people with PD in the UK and projects this will rise to 172,000 by
2030​[5]​. To put that into perspective for healthcare providers, a GP with a list size of 1,500
patients will see one new case of PD every 3.3 years​[6]​.

The underlying cause of idiopathic PD (the most common type of PD) is unknown, but risk
factors have been identified (see Box 1).

Box 1: Risk factors for Parkinson’s disease

Increasing age
Male gender
Head trauma
Common genetic mutations (e.g. LRRK2, GBA, SNCA)
Environmental toxin (e.g. 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine [MPTP])
exposure​[5–7]​

This article aims to provide a brief overview of PD, including symptoms and pharmacological
therapy. It also aims to provide practical tips on the management of medication for people
with PD.

Symptoms
In PD, the focus has traditionally been on motor symptoms caused by the loss of dopamine.
Motor symptoms of PD are not usually clinically apparent until at least 50% of dopaminergic
cell activity has been lost​[6]​.

The classical motor symptoms of PD are explained in Table 1​[2]​. Other motor symptoms
include dystonia, freezing and postural instability​[5–7]​.

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 Table 1: Classical motor symptoms

Non-motor symptoms are being increasingly recognised and, in many cases, have a bigger
impact on quality of life than motor symptoms​[3]​. Non-motor symptoms affect many systems
in the body. Box 2 lists some examples.

Box 2: Non-motor symptoms of Parkinson’s disease

Constipation;
Sleep disorders (e.g. restless leg syndrome, rapid eye movement sleep behaviour
disorder, excessive daytime sleepiness, insomnia);
Autonomic disturbance (e.g. orthostatic hypotension, urinary urgency, erectile
dysfunction and sweating);
Neuropsychiatric symptoms (e.g. mild memory and thinking difficulties, anxiety,
dementia, depression, hallucinations, sleep disorders, delusions);
Speech and swallow impairments (e.g. impaired swallowing, drooling and voice/speech
disorder);
Eye problems (e.g. excessive tearing);
Pain (e.g. musculoskeletal pain, Parkinson’s-related chronic central or visceral pain);
Fatigue;
Olfactory disturbance​[8]​.

There are many potential symptoms of PD and no two experiences of PD will be the same.
Each person will experience a different combination of symptoms and an individual rate of
progression of those symptoms​[8]​. Traditional thinking labels PD as a movement disorder

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and, often, the most obvious symptoms are indeed motor related (see Figure 1). However,
studies confirm that non-motor symptoms often have a bigger impact on quality of life than
motor symptoms​[3]​.

Many tools and scales are available to assess both disease progression and the impact of
symptoms on quality of life. These include the Movement Disorder Society sponsored
revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), which assesses the
course of disease, and the non-motor symptoms questionnaire, both specific and validated to
PD​[9,10]​. Disease progression is often described in stages (see Figure)​[8]​.

Figure: Typical patterns of progression in Parkinson’s

disease

Diagnosis
PD develops gradually; it can be months or years before symptoms become apparent
enough for someone to seek medical advice. Evidence of the prodromal phase lasting up to
20 years before diagnosis is emerging, with symptoms of hyposmia, reduced sense of smell,
rapid eye movement (REM) sleep behaviour disorder, depression and anxiety reported
before the motor symptoms appear​[11]​. These non-motor symptoms may be the result of
compensatory activity of other neurotransmitters (e.g. serotonin)​[12]​.

The umbrella term ‘Parkinsonism’ is used to describe symptoms or signs found in PD that
can also be found in other conditions​[7]​. Diseases that exhibit Parkinsonian symptoms but
are not idiopathic PD include multiple system atrophy, progressive supranuclear palsy,

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vascular PD and drug-induced Parkinsonism​[8]​. Medications associated with drug-induced
Parkinsonism — for example, older generation antipsychotics, antihistamines such as
cinnarizine, methyldopa and antiemetics, such as metoclopramide — typically inhibit the
actions of dopamine in the brain​[13]​.

Diagnosis of PD is based on clinical presentation, as there is no reliable diagnostic test. This

can lead to uncertainty in diagnosis, which formed the basis of the National Institute for
Health and Care Excellence (NICE) recommendation that diagnosis should be made by a
neurology specialist​[14]​. Misclassification in early disease is reported to occur in 15% of
cases diagnosed by a specialist; this figure is higher in non-experts​[14]​.

The Movement Disorder Society (MDS) criteria for diagnosis are based on presentation of
motor symptoms: bradykinesia plus rest tremor and/or rigidity. In addition, for a diagnosis of
PD, exclusion criteria must be absent and there must be no red flags. While not essential
criteria, the MDS now recommends that non-motor symptoms are taken into consideration
when considering a diagnosis of PD​[15]​.

Scans to assist diagnosis, although not definitive, are available (Table 2). A dopamine
transporter scan (DaTSCAN) is widely used as an additional tool in clinical practice, while
other types of single-photon emission computerised tomography (SPECT) scans are
reserved for clinical trials​[16]​. DaTSCAN cannot differentiate idiopathic PD from other types
of Parkinsonian syndrome, such as multiple system atrophy or progressive supranuclear
palsy.

Table 2: Difference between scans used in diagnosis of

Parkinson’s disease

Parkinson’s disease services

In the UK, people with PD usually have a named consultant specialist who they may see
once per year, where available, and a PD specialist nurse who is often pivotal in co-
ordinating care and providing support. Not all patients have a specialist nurse, and even
those who do may not be able to access support between routine appointments​[17]​. In some
areas, outreach and community teams are available and care is well integrated, but the

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recent Parkinson’s UK audit showed that this is not the case everywhere​[17]​. Given the
range of symptoms that patients can experience, optimal management of PD involves many
health and social care professionals to work together effectively​[13]​.

Table 3 details the roles and responsibilities of the wider multidisciplinary team​[13,14,18]​. It is
essential for pharmacists to find out what services are available in their areas and how to
access and refer patients to these services.

Table 3: Multidisciplinary team involvement in Parkinson’s

disease

Overall treatment is specific to the patient and the symptoms they experience. Symptoms
can be variable from day to day or even hour to hour; therefore, it is important that patients
have a good understanding of their treatment, disease, coping mechanism, support system
and regular reviews. Life expectancy can be normal; however, more advanced symptoms
can lead to increased disability and poor health, which may make someone more vulnerable
to complications (e.g. infection)​[8,19]​.

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Pharmacological management of motor symptoms

The Parkinson’s UK audit identified medicines management as a main area for improvement
in PD services, as a third of patients feel that they are not given enough information when
starting a new medicine (17). People with PD have a higher rate of emergency hospital
admission than the general population and are also twice as likely to stay in hospital; studies
suggest that medicines management plays a part in extended lengths of stay​[20]​.

The inpatient management of PD was previously covered in the learning article

‘Considerations for the inpatient management of Parkinson’s disease’.

There is no cure for PD and no drug treatments have been proven to impact disease
progression. Management is therefore symptomatic. Treatments to manage motor symptoms
work by increasing dopaminergic activity​[8]​. This is broadly achieved by three mechanisms:

1. Administration of dopamine precursor (e.g. levodopa preparations such as co-

careldopa);
2. Activation of dopamine receptors using dopamine agonists (e.g. ropinirole);
3. Enzyme inhibition to prevent the breakdown of dopamine (e.g. monoamine oxidase B
inhibitors [MAO-B] and catechol-O-methyl transferase [COMT] inhibitors).

[​20]​. The choice of first-line treatment has been long debated and there are no absolute rules
on which medication should be initiated first. NICE recommends that people with PD who
have symptoms affecting their daily life are offered a levodopa preparation as first-line
treatment. The PD MED Study supports this, showing that levodopa has advantages in the
management of motor symptoms when compared with dopamine agonists and monoamine
oxidase inhibitors. All other people with PD should be offered a levodopa preparation,
dopamine agonist or MAO-B inhibitor​[14]​. Interestingly, there was no significant difference in
benefits of dopamine agonists over monoamine oxidase inhibitors when chosen as initial
therapy​[21]​.

Anticholinergics, such as benztropine and trihexyphenidyl, are not routinely prescribed in

idiopathic PD but may be introduced for the management of tremor when dopaminergic
medications are not effective. However, they should be avoided in the elderly population as
they can cause hallucinations and confusion​[22]​.

Levodopa therapy

Levodopa treatment is gold standard and can be prescribed for all stages of PD​[21]​. It is
always given with concomitant dopa-decarboxylase inhibitors (carbidopa or benserazide) to
enable levodopa to cross the blood–brain barrier and prevent break down of levodopa to
dopamine in the gut (reducing side effects, such as nausea and vomiting)​[23]​. Long-term use
of levodopa can result in the patient experiencing dyskinesia and motor fluctuations (where
the patient experiences ‘off-time’ periods, as the drug wears off and symptoms re-emerge)​

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[8,24]​. The short half-life and reducing duration of action make it important that patients get
their medication on time every time. Strategies to help manage fluctuations in treatment
effect are listed in Table 4. The individual nature of PD means ‘on time’ is not the same time
or frequency for all patients. Late and missed doses contribute to risks of severe
complications (e.g. pneumonia and falls).

Catechol-O-methyl transferase inhibitors

The inhibition of COMT prevents peripheral breakdown of levodopa, allowing more levodopa
to reach the brain and prolonging the effect of levodopa dosing. As a result, concurrent
levodopa doses need to be reviewed and possibly reduced by up to 30%​[24]​. The COMT
inhibitor entacapone is usually taken with each levodopa dose and is available alone or as a
combination product with levodopa and carbidopa (which can be helpful in reducing tablet
burden)​[25]​. An alternative is opicapone, which is taken just once per day​[26]​.

Glutamate antagonists

Glutamate anatagonists, such as amantadine, are generally used to reduce dyskinesia

caused by levodopa therapy. They can be used in all stages of PD, but are often prescribed
when alternative strategies have not effectively managed motor complications​[24]​.

Dopamine agonists

Dopamine agonists stimulate dopamine receptors and require no modification. Preparations

include modified- and immediate-release tablets (e.g. pramipexole and ropinirole), patches
(rotigotine) and injections (apomorphine).

There are two subclasses of dopamine agonists — ergoline and non-ergoline agonists —
which both target dopamine D2-type receptors​[23]​. Ergoline dopamine agonists, which
include bromocriptine, pergolide, lisuride and cabergoline, are no longer routinely used in the
treatment of PD because of adverse fibrotic reactions​[27]​. Non-ergoline dopamine agonists
remain widely used and include ropinirole and pramipexole. Dopamine agonists may be less
likely to cause dyskinesia and motor fluctuations than levodopa​[21]​. Rotigotine is delivered
transdermally via a patch, which can be particularly useful where patients have a high tablet
burden or where patients have swallowing difficulties. Apomorphine is considered in
advanced PD (see below).

Some side effects of dopaminergic therapy are more common with dopamine agonists than
other therapies. Impulse-control disorders are one such symptom: studies show more than
50% of patients experience them on therapy, with incidence increasing with higher doses
and longer exposure​[28]​. However, this can occur at any stage of disease progression​[28]​. It
is therefore important that patients and their immediate support system are provided with
verbal and written support on this risk and are able to report any concerns​[29]​. Owing to the
high incidence rate, it is prudent to document that this consultation has taken place and also

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when any modification in treatment occurs. Typical presentations include addictive gambling,
hypersexuality, binge eating and obsessive shopping. Somnolence, day-time sleepiness and
hallucinations are also associated with PD and dopaminergic therapy, and are more common
with dopamine-agonist therapy​[8]​. Again, incidence increases with higher doses​[8]​.

Monoamine oxidase B inhibitors

MAO-B inhibitors increase the length of time dopamine is active in the brain by preventing it
from being broken down. Rasagiline and selegiline can be prescribed in early disease as
monotherapy, and any can be used in combination with other treatments later in the disease
course​[14]​. Concomitant antidepressants are cautioned with MAO-B inhibitors because of
the risk of serotonin syndrome. Hypertension is common when high-dose selegiline is taken
with tyramine-rich foods​[30]​.

General regimen complications and challenges

The progressive nature of PD inevitably means dosage increases and the need for new
medications and regimen adjustments on a regular basis. This often results in people
receiving combination therapy; for example, a levodopa preparation and an adjuvant agent,
with increasing frequency of dosing and an increasing number of products and/or
formulations making up those doses. Multiple formulation options and combinations can
make medication regimens appear very complicated. For co-beneldopa therapy alone, there
are six distinct products with three strengths and three formulations — even without
considering generic and branded products​[23]​.

This can be confusing for healthcare professionals, people with PD and their carers. Failure
to take medications on time (either intentionally or accidentally) can lead to serious
complications — for instance, deteriorating swallow and subsequent aspiration pneumonia
(the leading cause of death in PD). Parkinson’s UK has a long running ‘Get It On Time’
campaign with many initiatives to help support medicines adherence​[31]​.

It is important that all pharmacy professionals are aware and share the importance of
medication in PD. They can also play a vital role in helping to deliver strategies to reduce the
risk of missed doses; for example, ensuring stocks are available; setting recurring dose
alarms for patients and carers; and adding timings to labels, summary care
records/medicines reconciliations and drug charts, depending on area of practice.

Advanced therapies

Advance therapies are generally non-oral therapy options, which are used when patients are
no longer sensitive to oral drug therapy or are experiencing significant fluctuations, such as
sudden and unpredictable severe off periods. Deep brain stimulation, apomorphine and
levodopa–carbidopa intestinal gel can help symptom management for patients with
advanced PD​[32]​.

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Management of non-motor symptoms
Perhaps surprisingly, non-motor symptoms are reported to have the biggest impact on quality
of life​[3]​. First-line management may be non-pharmacological and pharmacists can signpost
to and work with other health and social care professionals involved in a patient’s care (e.g.
speech and language therapists in the management of drooling). Non-motor symptoms are
common but underreported, and there is a lack of quality evidence for their management​[33]​.
From the evidence that does exist and experience in clinical practice, some treatment
options are established.

Constipation

Autonomic dysfunction is common in PD and often presents as constipation. Muscles in the

bowel wall slow down, making it difficult for food to move along the gastro-intestinal tract​[34]​.
It is important this is managed, as constipation can also affect absorption of medication and
exacerbate symptoms. Macrogol, an osmotic laxative, is a first-line therapy for treating
constipation. Alternative laxatives may be tried if macrogol is not effective. In addition,
ensuring a high-fibre diet, exercise (if possible) and adequate fluid intake to prevent
constipation should be encouraged​[33]​.

Excessive daytime sleeping

PD medications, particularly dopamine agonists, can cause excessive daytime sleepiness or

sudden onset of sleep. People with PD are also more inclined to excessively sleep in the day
owing to interrupted sleep at night. NICE guidelines recommend the implementation of good
sleep hygiene measures — if these are not successful, medications can be adjusted
following advice from a specialist. If adjusting the patient’s medications does not work,
modafinil can be considered (this should be reviewed every 12 months after initiation by a
specialist)​[14]​. At the point of diagnosis of PD, patients must inform the Driver and Vehicle
Licensing Agency, as driving and medical assessments may need to be carried out​[35]​.
Patients who experience daytime sleepiness or sudden onset of sleep should not drive and
should inform their workplace in case of occupational hazards​[23]​.

Rapid eye movement sleep behaviour disorder

REM sleep behaviour is associated with PD and is a prodromal symptom in many cases​[8]​.
Patients with REM sleep disorder often physically act out vivid dreams during REM sleep,
which can affect their quality of life and that of their family and carers. NICE recommends the
off-label use of clonazepam or melatonin (pharmacists should ensure off-label use is
managed in line with local policy)​[14]​. Benzodiazepines are cautioned in the elderly
population; therefore, this patient cohort must be monitored closely by their care team if
started on clonazepam​[23]​.

Nocturnal akinesia

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Some people with PD have difficulty moving their body during sleep, which causes them to
stay in the same position for prolonged periods. This is known as nocturnal akinesia. It can
lead to complications such as pressure sores, breathing disorders and aspiration. It can be
helped with slow-release levodopa at night or oral, long-acting dopamine agonists. A
rotigotine patch may also be considered; however, there is limited evidence that rotigotine is
effective for nocturnal akinesia​[7]​.

Orthostatic hypotension

Also known as postural hypotension, orthostatic hypotension is defined as a fall in blood

pressure on standing; it can increase the risk of falls and so requires management. A
medication review should be undertaken to address pharmacological causes, such as
antihypertensives or anticholinergics. Other factors, such as dehydration, should also be
considered. Although evidence in PD is lacking, midodrine can be used to treat orthostatic
hypotension​[33]​. In this case, midodrine will only usually be initiated under the guidance of a
PD specialist for orthostatic hypotension if deemed appropriate. If midodrine is
contraindicated, fludrocortisone can be used (taking into consideration its safety profile [e.g.
cardiac risks])​[14,33]​.

Depression
Approximately 50% of people with PD experience depression​[8]​. These patients will require
specialist review. The NICE guideline on depression in adults with a chronic physical health
condition provides further guidance on appropriate antidepressants​[36]​.

Psychotic symptoms
Usually a side effect from dopaminergic medications, psychotic symptoms can cause
patients to experience visual hallucinations or delusions​[23]​. The first option for management
is specialist review and consideration of dopaminergic therapy dose reductions, particularly
for patients on dopamine agonists. Where medication reduction is not appropriate, does not
successfully manage psychosis, or where PD medications are optimised but symptoms
continue to be problematic, antipsychotics can be considered.

Typical antipsychotics are best avoided, as they block dopamine D2 receptors. Atypical
antipsychotics are preferred; although they block dopamine receptors, they have a lower
affinity and occupancy for dopaminergic receptors and a higher degree of occupancy of
serotoninergic receptors. Clozapine is recognised as the gold standard; however, clinicians
are often deterred from initiating clozapine owing to the monitoring profile of the drug.
Therefore, quetiapine is often prescribed for psychotic symptoms in patients with PD​[33]​.
Olanzapine, risperidone and other antipsychotic medications, such as phenothiazines and
butyrophenones, should be avoided as they can worsen motor features of PD by blocking
dopamine receptors more potently​[23,37]​.

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Parkinson’s disease dementia

NICE recommends treating PD dementia with cholinesterase inhibitors (e.g. rivastigmine) or

a glutamate receptor antagonist (e.g. memantine). However, there is a risk of cognitive
impairment with antimuscarinic medicines (e.g. oxybutynin, amitriptyline or tolterodine) and
benzodiazepines. Therefore, treatment of PD dementia should be initiated under guidance
from a specialist after careful consideration of comorbidities and risk of adverse effects, and
a full medication review​[14]​.

Drooling of saliva

Pharmacological management for drooling of saliva should only be considered if speech and
language therapy is not available or has not been effective. Glycopyrronium bromide,
hyoscine hydrobromide patch and sublingual atropine can be used to manage
hypersalivation. Owing to reduced ability to cross the blood–brain barrier and, therefore,
reduced risk of cognitive side effects, glycopyrronium bromide is often preferred in PD. If not
successful, referral should be made to a specialist for review and consideration of botulinum
toxin type A​[7,14,38]​.

Opportunities for input from pharmacy professionals

As there is no cure for PD, medication management is crucial in managing the disease.
Pharmacy professionals can play a significant role in both primary and secondary care. It is
important that pharmacy professionals are familiar with PD symptoms and are aware of
which referral pathway is most suitable for the patient. Many of the symptoms are
straightforward to manage; for example, constipation, and simple interventions (see Table 4)
can make a big difference to the patient’s quality of life.

Pharmacy professionals should also be aware of local services that are available to both
patients and themselves. The Parkinson’s UK website provides support and resources for
healthcare professionals, patients and their family or carers​[39]​.

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 Table 4: Interventions pharmacists may consider

Conclusion
The management of PD is heavily reliant on medicines. Pharmacy professionals, therefore,
have an opportunity to make a real, positive difference to the lives of people with PD. Even
simple interventions can significantly improve quality of life, with no special expertise
required. As many healthcare professionals are involved in the care of people with PD, it is
essential for pharmacy professionals to be knowledgeable about the different referral
pathways and interventions available to provide high-quality, individualised, holistic care.

This article was updated on 29 June 2022 to add additional information

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Last updated 15 August 2022 11:21

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Peer reviewed article

This article has been peer reviewed by relevant subject experts prior to acceptance for
publication. The reviewers declared no relevant affiliations or financial involvement with any
organisation or entity with a financial involvement with any organisation or entity with a
financial interest in or in financial conflict with the subject matter or materials discussed in
this article.

Citation
The Pharmaceutical Journal, PJ, June 2022, Vol 308, No
7962;308(7962)::DOI:10.1211/PJ.2022.1.145572

1 comment
Parkinson's disease is a neurodegenerative disorder marked by motor impairments
caused by the damage of dopaminergic neurons in the substantia nigra and the
formation of Lewy bodies. The specific cause of the sickness, however, is unclear. It
affects the upper and lower extremities including facial muscles. An increase in the
frequency of the disease over the last decade has necessitated greater research to
develop advanced diagnostic tests and therapeutic regimens that would provide a
lasting cure for Parkinson's disease.

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