Levodopa is the preferred initial dopaminergic therapy to improve motor symptoms in people with early-stage Parkinson disease, according to new practice recommendations from the American Academy of Neurology.

Developed by an international panel of neurologists, the new guidelines advise that initial treatment with levodopa provides superior motor benefit compared to treatment with dopamine agonists, although levodopa is more likely to cause dyskinesia

Therefore, patients should be counselled on the benefits and risks of the various treatment options including monoamine oxidase B (MAO-B) inhibitors, the authors advise

For example, initial treatment with dopamine agonists may be preferred in some early PD patients  under 60 years of age who are at higher risk for the development of dyskinesia, according to the guidance published in Neurology.

Other recommendations include:

• Initially prescribe immediate release levodopa rather than controlled release levodopa or levodopa/carbidopa/entacapone
• Use the lowest effective dose of levodopa to minimize the risk of dyskinesia and other adverse effects
• Routinely monitor patients taking levodopa for their motor response to treatment and for the presence of dyskinesia, motor fluctuations, impulse control disorders, excessive daytime sleepiness, postural hypotension, nausea, and hallucinations, to guide dosage titration over time.
• Similarly, clinicians should inform the patient and caregiver of important side effects of dopamine agonists before prescribing; screen patients for risk factors for side effects and monitor repeatedly in follow-up of patients.

The guideline found that people are more likely to stop their treatment due to side effects when taking dopamine agonists and MAO-B inhibitors than when taking levodopa. It also found that people taking MAO-B inhibitors were more likely to require additional therapy within two to three years.

“We carefully reviewed the available research on the effectiveness and possible risks of medications to treat motor symptoms in people with early Parkinson’s disease and found that levodopa is usually the best first treatment for these symptoms,” said guideline lead author Dr Tamara Pringsheim of the University of Calgary in Alberta, Canada.

“Still, there are side effects with levodopa as well as other drugs, so it is important that a person newly diagnosed with Parkinson’s disease discusses all options with their neurologist before deciding on the best treatment plan for them,” she added.

“Choosing to start a medication is a collaborative decision between a person with Parkinson’s disease, their neurologist, and their caregiver,” said Dr Pringsheim.

“The right medication will depend on a person’s symptoms, age and life circumstances. They are encouraged to discuss the potential benefits and adverse effects of medication options with their neurologist and care team.”