Applied Evidence

Parkinson’s disease: A treatment guide

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By following this stepwise approach, you can confidently incorporate newer agents into your armamentarium with little or no consultation with subspecialists.


› Use carbidopa/levodopa as first-line treatment for most patients with Parkinson's disease. A

› Prescribe rasagiline or entacapone for the treatment of motor fluctuations secondary to dopaminergic therapies. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series


From The Journal of Family Practice | 2018;67(5):276-279,284-286.


Parkinson’s disease (PD) can be a tough diagnosis to navigate. Patients with this neurologic movement disorder can present with a highly variable constellation of symptoms,1 ranging from the well-known tremor and bradykinesia to difficulties with activities of daily living (particularly dressing and getting out of a car2) to nonspecific symptoms, such as pain, fatigue, hyposmia, and erectile dysfunction.3

Furthermore, medications more recently approved by the US Food and Drug Administration (FDA) have left many health care providers confused about what constitutes appropriate first-, second-, and third-line therapies, as well as add-on therapy for symptoms secondary to dopaminergic agents. What follows is a stepwise approach to managing PD that incorporates these newer therapies so that you can confidently and effectively manage patients with PD with little or no consultation.

First, though, we review who’s at greatest risk—and what you’ll see.

Family history tops list of risk factors for PD

While PD occurs in less than 1% of the population ≥40 years of age, its prevalence increases with age, becoming significantly higher by age 60 years, with a slight predominance toward males.4

A variety of factors increase the risk of developing PD. A well-conducted meta-analysis showed that the strongest risk factor is having a family member, particularly a first-degree relative, with a history of PD or tremor.5 Repeated head injury, with or without loss of consciousness, is also a factor;5 risk increases with each occurrence.6 Other risk factors include exposure to pesticides, rural living, and exposure to well water.5

Researchers have conducted several studies regarding the effects of elevated cholesterol and hypertension on the risk of PD, but results are still without consensus.5 A study published in 2017 reported a significantly increased risk of PD associated with having hepatitis B or C, but the mechanism for the association—including whether it is a consequence of treatment—is unknown.7

Parkinson's disease: A treatment guide image

Smoking and coffee drinking. Researchers have found that cigarette smoking, beer consumption, and high coffee intake are protective against PD,5 but the benefits are outweighed by the risks associated with these strategies.8 The most practical protective factors are a high dietary intake of vitamin E and increased nut consumption.9 Dietary vitamin E can be found in almonds, spinach, sweet potatoes, sunflower seeds, and avocados. Studies have not found the same benefit with vitamin E supplements.9


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