Intended for healthcare professionals

Practice Therapeutics

Initial drug treatment in Parkinson’s disease

BMJ 2015; 351 doi: (Published 18 September 2015) Cite this as: BMJ 2015;351:h4669
Symptomatic treatment of Parkinson’s disease infographic
Click for an interactive graphic, showing more treatments for initial management of Parkinson’s disease.

  1. Sharon Muzerengi, clinical research fellow neurology12,
  2. Carl E Clarke, professor of clinical neurology13
  1. 1School of Clinical and Experimental Medicine, College of Medicine and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
  2. 2University Hospital Birmingham Foundation Trust, Queen Elizabeth Hospital, Birmingham
  3. 3Department of Neurology, Sandwell and West Birmingham Hospitals NHS Trust, City Hospital, Birmingham
  1. Correspondence to: S Muzerengi shammuzerengi{at}

The bottom line

  • First line treatments for Parkinson’s disease include levodopa, non-ergot dopamine agonists, and monoamine oxidase B inhibitors

  • Consider starting levodopa treatment in all (except young) patients, especially those with serious motor impairment (because it has greater motor benefits than other drugs) or cognitive impairment (because it has fewer neuropsychiatric complications than dopamine agonists)

  • Monitor for motor complications (dyskinesias, motor fluctuations) and impulsivity and adjust doses accordingly

  • Do not stop treatment abruptly because this may cause malignant hyperthermia (Parkinson hyperpyrexia syndrome)

A 69 year old retired bus driver with no medical history of note presented to the outpatients department with a three year history of progressive tremor of the right hand; slowness of movement; and difficulty turning in bed at night, buttoning shirts, and using cutlery. He is keen to know what is wrong and whether it can be treated.

What drugs are available for initial treatment of Parkinson’s disease?

Parkinson’s disease is a progressive neurodegenerative disorder characterised by tremor, rigidity, bradykinesia, and a wide spectrum of non-motor symptoms including sleep disorders, hyposmia, bladder and bowel dysfunction, fatigue, dementia, and other neuropsychiatric symptoms.1

Although the disease has no cure, available treatments effectively control motor symptoms and improve quality of life.2 3 Several drug classes are licensed for use as monotherapy in early Parkinson’s disease and adjuvant therapy in later disease:

  • Levodopa is the main precursor in dopamine synthesis and has been the mainstay of treatment for decades

  • Dopamine agonists simulate dopamine by binding directly to post-synaptic dopamine receptors in the striatum.4 They include:

    • -Non-ergot dopamine agonists (oral pramipexole and ropinirole, and transdermal rotigotine)

    • -Ergot derived dopamine agonists (cabergoline, bromocriptine, and pergolide): their use requires frequent monitoring for complications of heart valve and retroperitoneal fibrosis, so the National Institute for Health and Care Excellence guidelines recommend non-ergot dopamine agonists instead5

  • Monoamine oxidase B inhibitors (rasagiline and selegiline) selectively inhibit …

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