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Treating the Motor Symptoms of Parkinson Disease

Morgan, John C. MD, PhD; Fox, Susan H. MBChB, MRCP(UK), PhD

doi: 10.1212/CON.0000000000000355
Review Articles

ABSTRACT Purpose of Review: After a patient is diagnosed with Parkinson disease (PD), there are many therapeutic options available. This article provides examples of prototypical patients encountered in clinical practice and illustrates the various pharmacologic and nonpharmacologic treatment options for the motor symptoms of PD.

Recent Findings: Levodopa became available in the late 1960s and remains the gold standard for the treatment of PD even today. Since that time, amantadine, monoamine oxidase type B inhibitors, dopamine agonists, and catechol-O-methyltransferase inhibitors have emerged as monotherapy, add-on therapies, or both, in the armamentarium against PD. The most appropriate time to start such drugs remains a clinical decision according to patient symptoms. However, earlier use of levodopa is the more common practice due to its superior benefit and the side effects of dopamine agonists. Deep brain stimulation continues to be the most effective treatment for motor symptoms in appropriate patients, and advances in technology may improve efficacy. New ways to deliver levodopa have emerged (effective extended-release oral preparations and levodopa/carbidopa intestinal gel), and these medications provide additional options for certain patients. Exercise and neurorehabilitation are increasingly recognized as important tools to combat the motor symptoms of PD. Nondopaminergic drugs may help non–levodopa-responsive motor symptoms.

Summary: Treatment of PD is multifaceted and requires a tailored pharmacotherapeutic and nonpharmacologic approach for a given patient. Patients should be at the center of care, and clinicians should try to provide optimum benefit through the many treatment options available.

Address correspondence to Dr John C. Morgan, Movement Disorders Program, Department of Neurology, Medical College of Georgia, Augusta University, 1429 Harper Street, HF-1154, Augusta, GA 30912, jmorgan@augusta.edu.

Relationship Disclosure: Dr Morgan has received personal compensation as a speaker and consultant for Impax Laboratories Inc and Teva Pharmaceutical Industries Ltd, as a speaker for the National Parkinson Foundation, and as a consultant for AbbVie, Acadia Pharmaceuticals, Acorda Therapeutics, Cynapsus Pharmaceuticals Inc, Lundbeck, UCB Inc, and Veloxis Pharmaceuticals. Dr Morgan has received research/grant support as principal investigator or subinvestigator from AbbVie, ACADIA Pharmaceuticals Inc, Biotie Therapies, Civitas Therapeutics, Kyowa Hakko USA Inc, Lundbeck, the National Institutes of Health, National Parkinson Foundation, and the Parkinson Study Group, and has served as an expert witness in various court cases. Dr Fox has received salary support for serving as the co-editor of the International Parkinson and Movement Disorder Society website, as a speaker for Ipsen Pharmaceuticals, Inc; Teva Pharmaceutical Industries Ltd; and Zambon Company SpA; and for serving on the advisory boards of Lundbeck, Orion Pharma Ltd, and Novartis International AG. Dr Fox has received research/grant support from Avanir Pharmaceuticals, the Michael J. Fox Foundation, the National Institutes of Health, and Parkinson Society of Canada and has received research/grant support as site principal investigator for clinical studies from Adamas Pharmaceuticals Inc, Cynapsus Pharmaceuticals Inc, and Kyowa Hakko USA Inc. Dr Fox receives royalties from Oxford University Press.

Unlabeled Use of Products/Investigational Use Disclosure: Drs Morgan and Fox discuss the unlabeled/investigational use of amantadine and methylphenidate for freezing gait disorders, the use of clozapine and mirtazapine for tremor in Parkinson disease, and the use of anti–α-synuclein antibodies, caffeine, coenzyme Q10, creatine, inosine, isradipine, nicotine, nilotinib, pioglitazone, and rasagiline as failed or potential disease-modifying therapies.

Supplemental digital content: Videos accompanying this article are cited in the text as Supplemental Digital Content. Videos may be accessed by clicking on links provided in the HTML, PDF, and app versions of this article; the URLs are provided in the print version. Video legends begin on page 1083.

© 2016 American Academy of Neurology
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