Editor's Choice

Parkinson's disease: a journey

BMJ 2004; 329 doi: http://dx.doi.org/10.1136/bmj.329.7466.0-h (Published 09 September 2004) Cite this as: BMJ 2004;329:0-h
  1. Kamran Abbasi, acting editor (kabbasi{at}bmj.com)

    Some drugs are like weapons of mass destruction: often heard about but seldom seen. Selegiline, a monoamine oxidase type B inhibitor, was hailed in the 1980s as a drug that might alter the clinical course of idiopathic Parkinson's disease—and not just relieve symptoms (p 581). A research paper published in the BMJ in 1995 (bmj.com/cgi/content/full/311/7020/1602) curbed that optimism by indicating that people taking selegiline and levodopa had a higher risk of death than those taking levodopa alone. Now this week's issue carries a meta-analysis of 17 trials comparing monoamine oxidase type B inhibitors with placebo and finds this class of drug improves symptoms, delays the use of levodopa, and lower doses can be used once levodopa is required (p 593).

    Reclaiming older, cheaper drugs on the basis of sound evidence has become fashionable and the ALLHAT trial signalled a preference for thiazide diuretics over more modern treatments for hypertension. With a sweet $800m estimated to develop a new drug, industry's enthusiasm for promoting modern therapies is understandable—but undesirable—as is its reluctance to share negative findings about products (pp 587, 590).

    Yet does this latest meta-analysis point to widespread use of monoamine oxidase B inhibitors? Editorialists Yoav Ben-Shlomo and Kailash Bhatia urge caution. Yes, these drugs are beneficial in younger and otherwise healthy people, but their safety in combination and their efficacy compared with other first line drugs has not been proved. A funnel plot, say Ben-Shlomo and Bhatia, hints at publication bias. What does this shadow boxing do for trust in the findings of clinical research? Where does this leave patients? Ben-Shlomo and Bhatia reach the same conclusion that clinicians in many disparate situations are now reaching: the best choice of treatment will be the patient's.

    Mary Baker and Lizzie Graham warn that doctors should remember that people with Parkinson's disease “value physical therapy as much as, if not more than, medication to help them move and remain active” (p 611). In the first of a new genre of BMJ articles that we hope will help readers understand the experiences of people living with chronic disease—a journey that encompasses good and bad news, companions, coping strategies, much solitude, false trails, and travellers' tales—Baker and Graham map out a life with Parkinson's disease, and Peter Lapsley and Trish Groves explain our rationale for publishing the “patient's journey” articles and how readers can contribute their own (p 582).

    Every journey has a beginning and an ending, however fuzzy, and this week's cover captures Muhammad Ali, one of the world's most famous sportsmen, at the start of his journey with Parkinson's disease. Ali's exploits in Africa are well documented. Less well documented is the plight of doctors in Uganda, where nearly a third of graduates from one medical school have had an all too brief life journey. with AIDS (p 600).

    Footnotes

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