Management of Early PD

• Educate, support and advise Initiate protective therapies, e.g., antioxidants, selegiline 5mg daily
• Treat constipation with dietary change, stool softeners or laxatives
• Treat sleep disturbance with low dose tricyclic antidepressants, e.g., amytriptyline
• Encourage physical and mental exercises
• Start selegiline early (mild therapeutic effect; may slow down disease progression)

Management of Early to Mid-Stage PD

• Continue antioxidant diet and selegiline
• Add a dopamine agonist (e.g., ropinirole, pramipexole, bromocriptine, pergolide, cabergoline, lisuride, amantadine, apomorphine) for bradykniesia, tremor, stiffness or postural instability
• Add an anticholinergic (e.g., trihexiphenidyl) for tremor if tolerated
• Add levodopa for falls or in an older patient
• Use combination therapy (e.g., levodopa therapy and dopamine agonists, or levodopa and COMT inhibitor) if wearing-off or fluctuations are present

Management of Mid/Late-Stage PD

• Provide gait and balance training if falling is a problem
• Treat constipation aggressively, as it can interfere with medication absorption
• Add COMT inhibitor (entacapone) to levodopa if wearing-off or fluctuations develop
• Adjust dopamine agonist dose if wearing-off or fluctuations occur, and take after meals or adjust the dose or change agonist if there are side-effects
• Adjust levodopa dose, especially if falls or side-effects occur
• Add amantadine for levodopa-induced dyskinesias and dystonia
• Add apomorphine subcutaneously if the patient experiences sudden "offs" or severe motor fluctuations
• Other agents which may be of benefit include benzodiazepines for anxiety and tremor, atypical neuroleptics for hallucinations, delusions or tremor, and liquid levodopa for rapid absorption and quick recovery from sudden "offs".