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![]() SECTION THREEStarting TreatmentTOPICS ON THIS PAGE:What Treatment? New Drugs LINKS TO:
Principles of Management LINKS BACK TO:
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A lot of people ask this, and the answer is that it is very variable. It varies with the patient; it varies with the doctor. Treatment should be individualised. Everyone is slightly different, with different requirements and different needs. If I see someone very early on in the disease, and they are doing well, then I don't offer symptomatic relief, other than to support, educate, and use measures that may slow it down. If they have tremor and are embarrassed by that, we have a chat about it. Do they want treatment for the tremor? Tremor is not that disabling unless it interferes with the patient using his hands. Most tremor in Parkinson's is there when you are at rest, but when you use your hands, it goes away. It really depends on the patient. Generally Recommended Treatment for Different Age Groups
For those under fifty, I would prescribe selegiline (Eldepryl), but I would tend to use a lower dose of this, as it can keep you awake at night if you take it late in the day. I just use 5mg of selegiline, half the usual dose, as it is enough to do the job. It may possibly slow down the progression of the disease. It definitely helps the symptoms; whether or not it slows down disease progression is as yet unproven. I tend to be a little biased against anticholinergics. I agree that they are better tolerated in the younger patient, but in the older patient, they can affect the memory, cause constipation, dry mouth, urinary retention. They can be difficult to use, so I would use them only occasionally. Alternatively, I would use a dopamine agonist, even in the under-fifties. I tend not to use slow-release levodopa on the basis that, if you are constipated as can happen in PD (the Lewy bodies in the brain are also found in the gut, and the nervous system in the gut is also affected in PD - it also slows down), the slow-release drugs may not be fully absorbed. In the over-sixties, I would generally use up to 300mg levodopa a day, and try to hold it down as much as possible, for as long as possible, and supplement it with Comtess, which lengthens the effect of Sinemet/Madopar. In trying to get the best result, there are no hard and fast rules. I would use dopamine agonists even in the older age group. The newer dopamine agonists tend to have fewer side-effects, and by using them you run into less trouble with them in the long-term.
All the drugs have side-effects, so my rule is to start/change a drug slowly, go up slowly, down slowly, change one drug at a time. You don't stop taking any drug abruptly in Parkinson's, nor do you start or stop two drugs at the same time.
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