Table 3:

Summary of recommendations for treatment of motor symptoms

Recommendation numberRecommendationSourceGrade
General considerations
C23People with PD should have regular access to the following:
  • Clinical monitoring and medication adjustment

  • A continuing point of contact for support, including home visits, when appropriate

  • A reliable source of information about clinical and social matters of concern to people with PD and their caregivers, which may be provided by a PD nurse specialist.

NICE7C
C24Antiparkinsonian medication should not be withdrawn abruptly or allowed to fail suddenly owing to poor absorption (e.g., gastroenteritis, abdominal surgery), to avoid the potential for acute akinesia or neuroleptic malignant syndrome.NICE7D
GPP
C25The practice of withdrawing patients from their antiparkinsonian drugs (so-called “drug holidays”) to reduce motor complications should not be undertaken because of the risk of neuroleptic malignant syndrome.NICE7D
GPP
C26In view of the risks of sudden changes in antiparkinsonian medication, people with PD who are admitted to hospital or care homes should have their medication: i) given at the appropriate times, which in some cases may mean allowing self-medication; ii) adjusted by, or adjusted only after discussion with, a specialist in the management of PD.NICE7D
GPP
C27Surveillance for dopamine dysregulation syndrome should be undertaken in patients receiving levodopa or intermittent apomorphine.SIGN13GPP
C28When starting dopamine agonist therapy, people and their family members and caregivers (as appropriate) should be given verbal and written information about the following, and the discussion should be recorded as having taken place:
  • The increased risk of developing impulse control disorders when taking dopamine agonist therapy, and that these may be concealed by the person affected

  • The different types of impulse control disorders (e.g., compulsive gambling, hypersexuality, binge eating and obsessive shopping)

  • Who to contact if impulse control disorders develop

  • The possibility that if problematic impulse control disorders develop, dopamine agonist therapy will be reviewed and may be reduced or stopped.

NICE8GPP
C29It should be recognized that impulse control disorders can develop in a person with PD who is on any dopaminergic therapy at any stage in the disease course.NICE8GPP
Pharmacologic therapy in early PD
C30Before starting treatment for people with PD, the following should be discussed:
  • The person’s individual clinical circumstances; for example, their symptoms, comorbidities and risks from polypharmacy

  • The person’s individual lifestyle circumstances, preferences, needs and goals

  • The potential benefits and harms of the different drug classes.

NICE8GPP
C31Levodopa may be used as a symptomatic treatment for people with early PD.NICE7A
C32The dose of levodopa should be kept as low as possible to maintain good function in order to reduce the development of motor complications.NICE7A
C33Controlled-release formulations of levodopa or adding entacapone are not effective for delaying motor complications.EFNS14A
C34Dopamine agonists may be used as a symptomatic treatment for people with early PD.NICE7A
C35A dopamine agonist should be titrated to a clinically efficacious dose. If adverse effects prevent this, another agonist or a drug from another class should be used in its place.NICE7D
GPP
C36Ergot-derived dopamine agonists should not be used as first-line treatment for PD.SIGN13B
C37When an ergot-derived dopamine agonist is used, patients should undergo:
  • Baseline echocardiographic screening and regular follow-up echocardiographic testing to identify cardiac abnormalities

  • Baseline laboratory (ESR, serum creatinine) and radiological (e.g., chest x-ray) investigations with regular follow-up surveillance to identify serosal fibrosis.

SIGN13GPP
C38MAO-B inhibitors may be used as a symptomatic treatment for people with early PD.NICE7A
C39There is insufficient evidence to support the use of amantadine in the treatment of patients with early PD.SIGN13A
C40Anticholinergic drugs should not be used as first-line treatment in patients with PD.SIGN13B
C41Beta-adrenergic antagonists may be used in the symptomatic treatment of selected people with postural tremor in PD, but should not be drugs of first choice.NICE7D
GPP
Pharmacologic therapy for motor symptoms in later PD
C42The choice of an adjunct to levodopa for people with PD who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy should take into account:
  • The person’s individual clinical circumstances; for example, their PD symptoms, comorbidities and risks from polypharmacy

  • The person’s individual lifestyle circumstances, preferences, needs and goals

  • The potential benefits and harms of the different drug classes.

NICE8GPP
C43Catechol-O-methyltransferase inhibitors (entacapone) and MOA-B inhibitors (rasagiline) may be considered for the reduction in off-time in patients with advanced PD who have motor fluctuations.SIGN13A
C44Dopamine agonists (oral [pramipexole, ropinirole] or transdermal [rotigotine]) may be considered for the management of motor complications in patients with advanced PD.SIGN13A
C45Levodopa controlled release may improve wearing-off (grade: C) and nighttime akinesia (grade: GPP).EFNS14Varied
C46Subcutaneous apomorphine infusions or injections may be considered for the management of severe motor complications, but should be provided only in units that have sufficient experience and resources.SIGN13C
C47Intrajejunal levodopa-carbidopa enteric gel administered through percutaneous gastrostomy may be considered for the reduction of off-time or to reduce dyskinesia.EFNS14C
C48Amantadine is recommended for the treatment of dyskinesia in PD (200–400 mg/d).EFNS14A
Surgery
C49Deep brain stimulation of the STN or the GPi is effective against motor fluctuations and dyskinesia.EFNS14A
C50With the current evidence, it is not possible to decide if the STN or GPi is the preferred target for deep brain stimulation for people with PD, or whether 1 form of surgery is more effective or safer than the other.NICE7D
C51Thalamic deep brain stimulation may be considered as an option in people with PD who predominantly have severe disabling tremor.NICE7D
C52Unilateral pallidotomy is efficacious at reducing contralateral dyskinesia.EFNS14A
C53Unilateral thalamotomy improves contralateral tremor and rigidity but has no consistent effect on akinesia.EFNS14D
C54Preoperative response to levodopa should be considered as a factor predictive of outcome after deep brain stimulation of the STN.AAN17B
C55Age and duration of PD may be considered as factors predictive of outcome after deep brain stimulation of the STN. Younger patients with shorter disease durations may possibly have improvement greater than that of older patients with longer disease durations.AAN17C
Rehabilitation
C56Consideration should be given to referring people who are in the early stages of PD to a physiotherapist with experience of the disease for assessment, education and advice, including information about physical activity.NICE8B
C57Physiotherapy specific to PD should be offered to people who are experiencing balance or motor function problems.NICE8A
C58Consideration should be given to referring people who are in the early stages of PD to an occupational therapist with experience of PD for assessment, education and advice on motor and nonmotor symptoms.NICE8B
C59Occupational therapy specific to PD should be offered to people who are having difficulties with activities of daily living.NICE7A
C60Speech and language therapy should be offered to people with PD who are experiencing problems with communication, swallowing or saliva. Therapy should include:
  • Strategies to improve the safety and efficiency of swallowing to minimize the risk of aspiration, such as expiratory muscle stress

  • Strategies to improve speech and communication, such as attention to effort therapies.

NICE8A
C61Consideration should be given to referring people for alternative and augmentative communication equipment that meets their communication needs as PD progresses and their needs change.NICE8GPP
C62Discussion should take place about a diet in which most of the protein is eaten in the final main meal of the day (a protein redistribution diet) for people with PD on levodopa who experience motor fluctuations.NICE8GPP
C63People with PD should be advised to avoid a reduction in their total daily consumption of protein.NICE8GPP
C64Consideration should be given to referring people with PD to a dietitian for specialist advice.NICE8GPP
C65People with PD should be advised to take a vitamin D supplement.NICE8B
GPP
C66People with PD should be advised not to take over-the-counter dietary supplements without first consulting their pharmacist or other health care professional.NICE8GPP
  • Note: AAN = American Academy of Neurology practice parameters,18 EFNS14 = European Federation of Neurological Societies — Motor Guidelines,14 ESR = erythrocyte sedimentation rate, GPi = globus pallidus interna, GPP = good practice point, MAO-B = monoamine oxidase B, NICE7 = National Institute for Health and Clinical Excellence 2006 PD Guidelines,7 NICE8 = National Institute for Health and Clinical Excellence — 2017 PD Guidelines,8 PD = Parkinson disease, SIGN13 = Scottish Intercollegiate Guidelines Network,13 STN = subthalamic nucleus.