Delaying Treatment

Key Facts

  • Delaying treatment is controversial.
  • Deciding when to start is a quality of life issue and not a disease progression issue.
  • There is no evidence that delaying therapy results in longer benefit from levodopa. The prevalent myth that levodopa works for five years and then stops working is just that–a myth.

Clinical Best Practices

  • Assess each patient individually to determine when treatment should be initiated.
  • Refer to neurologist/movement disorder specialist if you are not sure about initiating treatment.

Clinical trials do not address the best timing to start dopaminergic therapy in PD. Treatment should be tailored to the needs of each patient and delaying treatment may be an option for many of them. You should aim to maintain a good quality of life for your patient.

Benefits of Delaying Initiation

  • Providing time for patients and families to adjust to the diagnosis and therefore develop better clinician rapport
  • Allowing patients to “research” and therefore develop questions regarding drug initiation, delaying the “sick role”
  • Allowing other therapies including physiotherapy and speech therapy to be instituted
  • Remembers that many patients who have not started treatment may be able to participate in clinical trials

Risks of Delaying Initiation

  • Decreased quality of life
  • Motor disability
  • Restriction of social and physical activities compounding disability or resulting in job loss or change in relationships
  • Morbidity due to falls
  • Greater risk of side effects should cholinesterase inhibitors be initiated for cognitive decline
  • Lack of patient and family engagement in therapeutic regime

Medications to Avoid

There are some medications to avoid because they worsen PD:

Anti-nausea pills 

  • Metoclopramide (Reglan)
  • Prochlorperazine (Compazine)
  • Promethazine (Phenergan)

Neuroleptics (tranquilizers)

  • Haloperidol (Haldol)
  • Chlorpromazine (Thorazine)
  • Thioridazine (Mellaril)
  • Perphenazine (Trilafon)
  • Perphenazine and amitriptyline (Triavil)
  • Thiothixene (Navane)
  • Fluphenazine (Prolixin)
  • Aripiprazole (Abilify)
  • Olanzapine (Zyprexa)
  • Risperidone (Risperdal)
References: 

Asimakopoulos P, Caslake R, Harris CE, Gordon JC, Taylor KS, Counsell C. Changes in quality of life in people with Parkinson's disease left untreated at diagnosis. Neurol Neurosurg Psychiatry.2008;79(6):716 -718.

Fahn S, Oakes D, Shouldon I, et al; Parkinson Study Group. Levodopa and progression of Parkinson’s disease. N Engl J Med. 2004;351(24):2498-2508.

Marras C, Lange AE, Eberly SW, et al; Parkinson Study Group DATATOP and PRECEPT investigators.  Mov Disord. 2009; 24(16):2370-2378.