Abstract
BackgroundEarly initiation of pharmacotherapy in Parkinson's disease (PD) is nowadays widely advocated by experts since the delay of treatment has shown to be associated with a significant deterioration of health related quality of life in affected patients. Due to marked advances in PD treatment during the last decades, physicians are nowadays fortunately equipped with a variety of substances that can effectively ameliorate emerging motor symptoms of the disease, among them levodopa, dopamine agonists and monoamine oxidase type B (MAO-B) inhibitors. Despite numerous drug intervention trials in early PD, there is however still ongoing controversy among neurologists which substance to use for the initial treatment of the disease.DiscussionIn multiple studies, MAO-B inhibitors, such as selegiline and rasagiline, have shown to provide mild symptomatic effects, delay the need for levodopa, and to reduce the incidence of motor fluctuations. Although their symptomatic efficacy is inferior compared to dopamine agonists and levodopa, MAO-B inhibitors undoubtedly have fewer side effects and are easy to administer. In contrary to their competitors, MAO-B inhibitors may furthermore offer a chance for disease modification, which so far remains a major unmet need in the management of PD and eventually makes them ideal candidates for the early treatment of the disease.SummaryMAO-B inhibitors may constitute a preferable therapeutic option for early PD, mainly due to their favourable safety profile and their putative neuroprotective capabilities. Since the symptomatic effects of MAO-B inhibitors are comparatively mild, dopamine agonists and levodopa should however be considered for initial treatment in those PD patients, in whom robust and immediate symptomatic relief needs to be prioritized.
Highlights
Initiation of pharmacotherapy in Parkinson’s disease (PD) is nowadays widely advocated by experts since the delay of treatment has shown to be associated with a significant deterioration of health related quality of life in affected patients
Since the symptomatic effects of monoamine oxidase type B (MAO-B) inhibitors are comparatively mild, dopamine agonists and levodopa should be considered for initial treatment in those PD patients, in whom robust and immediate symptomatic relief needs to be prioritized
Daily treatment with 10 mg selegiline (N-Propargylmethamphetamine) in the Deprenyl and Tocopherol Antioxidative Therapy of Parkinsonism (DATATOP) study was associated with an improvement of about 3 points on the total Unified Parkinson’s Disease Rating Scale (UPDRS) and 1.7 points on the motor subscale of the UPDRS compared to placebo after 3 months [4]
Summary
MAO-B inhibitors provide mild symptomatic effects in early PD Several large-scale, randomized placebo-controlled clinical trials have demonstrated that treatment with MAOB inhibitors leads to a symptomatic amelioration of early PD [4,5,6,7,8,9]. Once daily drugs had significantly better adherence when compared with drugs prescribed more frequently, which strongly supports the usage of novel extended-release formulations of dopamine agonists or of MAO-B inhibitors, whereas the latter are capable to provide a more sustained and continuous stimulation of the post-synaptic dopaminergic receptors by prolonging the half-life of dopamine in the basal ganglia Another possible obstacle to regular medication intake in PD patients may be dysphagia, which more common in advanced stages can be observed in early PD [48,49]. Summary Despite ongoing controversies among neurologists on how to initiate treatment in early PD there are compelling arguments for MAO-B inhibitors to be preferred in this situation In clinical studies, they have shown to ameliorate symptoms of the disease, to delay the need for levodopa and to reduce the incidence of motor fluctuations. HR has was acting on Advisory Boards and received honoraria and research funds from Abbott, Bayer HealthCare, Boehringer Ingelheim, Cephalon, Desitin, GlaxoSmithKline, Merck Serono, Novartis, Orion, Pfizer, Teva/Lundbeck, UCB Pharma and Valeant
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