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Treatments for non-motor symptoms or Parkinson’s disease evidence-based

By: Dr. Vikki Alvarez
Neurologist, Movement Disorders Specialist

The clinical diagnosis of Parkinson’s disease (PD) rests on the identification of the characteristics related to dopamine deficiency that are a consequence of degeneration of the substantia nigra pars compacta. For many decades, tremor, stiffness, slowness and gait disturbances were the hallmark of the disease. However, non-dopaminergic symptoms or non-motor symptoms are becoming just as important in the management and diagnosis and almost inevitably emerge with disease progression.

Indeed, non-motor symptoms dominate the clinical picture of advanced Parkinson’s disease and contribute to severe disability, impaired quality of life, and shortened life expectancy. Attention is now being focused on the recognition and quantitation of non-motor symptoms, which will form the basis of
improved treatments. Non-motor symptoms are very challenging to treat. Below, I summarized the evidence-based medicine approach review published by the movement disorders society website last 2014.

Drugs to treat depression in PD
SSRI like paroxetine still give insufficient result, and there are acceptable risks.
TCA/tricyclic antidepressant like amitriptyline insufficient evidence to conclude on the efficacy although is suggested to be possibly useful.
Newer antidepressants like venlafaxine are clinically useful with acceptable risks. Non-pharmacologic interventions like CBT (cognitive behavioral therapy)- possibly useful.

Drugs to treat dementia in PD
Acetylcholinesterase inhibitors like donepezil, galantamine and memantine have insufficient evidence with acceptable risks but possibly useful.
Rivastigmine is efficacious and clinically useful, has acceptable risks.

Drugs to treat psychosis in PD
Clozapine is efficacious and has acceptable risk.
Olanzapine is unlike;y efficacious
Quetiapine has insufficient evidence and therefore is currently being use for investigational purposes.

Drugs to treat disorders of sleep and wakefulness in PD
Caffeine- insufficient evidence to conclude on the efficacy
Melatonin- insufficient evidence to conclude on the efficacy although the practice implication is suggested to be possibly useful.

Drugs to treat fatigue in PD
Methyphenidate and modafinil have insufficient evidence/results and are currently investigational.

Drugs to treat pathological gambling in PD
Amantadine has insufficient evidence/results and is currently investigational.

Drugs to treat anorexia
Domperiodone is likely efficacious and possibly useful

Drugs to treat autonomic dysfunction in PD

Drus to treat Orthostatic hypotension
Fludrocortisone, domperidone, midodrin, dihydroergotamine, indomethacine, yohimbine have insufficient evidence/results and are currently investigational.
Droxidopa was recently approved by FDA to treat neurogenic orthostatic hypotension

Drugs to treat Sexual dysfunction in PD
Sildenafil has insufficient evidence, current practice is investigational.

Drugs to treat sialorrhea (drooling in PD)
Botulinum toxin type A and B- efficacious, clinically useful with acceptable risk Glycopyrrolate is efficacious with isufficient evidence
Ipratropium Bromide spray has insufficient evidence

Drugs to treat urinary frequency in PD
Oxybutynin, tolteradine, prazosin, desmopressin has insufficient evidence, current practice is investigational

Botulinum toxin: no recent guideline although the U.S. Food and Drug Administration expanded the approved use of Botox (onabotulinumtoxinA) to treat adults with overactive bladder who cannot use or do not adequately respond to a class of medications known as anticholinergics.

Drugs to treat constipation in PD
Macrogol is likely efficacious and useful
Lubiprostone insufficient evidence, likely useful

 

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