Once a patient is confirmed to have Parkinson’s Disease, what are the evidence- and guideline-based approaches to initiating pharmacotherapy and, sequencing therapy in cases that are refractory to initial therapy or that do not respond optimally?
actually how you select therapies and initiate therapies and add on therapies. Actually a very unique topic because each patient has done differently depending on what they present with the level of symptoms, what type of therapeutics and what other medical co morbid conditions they have. So if we look at the classes that are approved for initial monotherapy, we have our M A. O. B. Inhibitor class. The mono therapy drug that's approved is resettling. Then we have our dopamine agonist class where we have three agents approved for it, which is the right honorable prime pixel as well as writing routine, which is a transdermal system. In addition to that, we have the levodopa class as an option. And then we of course have our non dopamine ergic therapies which is a man to Dean as well as tryptophan, which is an anti colon ergic. So we have an anti glutamine ergic agent and an anti colon ergic agent. So this is kind of the early onset options of what we can use first line. Now, how we choose one. Well, we typically tend to go towards dopamine ergic therapies. Non dope energy therapies were used early on. Anti colonics are rarely used in cases unless there's a significant amount of tremor predominance, not because it's not effective but also because of the side effect potential in an aging population such as dry mouth mental fogginess balance issues. So we tend to steer clear or minimize anti coal energy. We tend to use a mandate in in some cases early on, but there's more tremor predominance. We tend to use early on with dopamine ergic therapies that I just mentioned now, if somebody has milder disabilities, we may start with levodopa sparing therapies. If somebody's younger onset, we may start with levodopa sparing therapies. So keep in Mind Parkinson's is a progressive disease. People will have fluctuations over the course of time and individuals have come to realize that early on, 20 years ago we were very much gung ho on dopamine sparing therapies. Uh, levodopa sparing therapies 20 years ago and over the time, pendulum has moved forward to really using a combination of therapies and poly pharmacy of sorts. So you're not using exclusively one therapy but a combination in that sense. So you may start with levodopa sparing therapies early on. The reason we do that is more so because we're hoping to delay, leave it open a milder population of patients that may not need it at that time. The other reason we may use it earlier on with levodopa sparing therapies earlier on is because we may want to uh use less pill burden up front because levodopa when started as a minimum of typically, you know, three times a day dozing. Whereas some of the dopamine medications and the MLB inhibitors are once a days. Now, that's how we generally would approach it, how somebody with moderate disability, significant impairments. We would start with levodopa first adjust the levodopa and then add an adjunctive therapy such as dopamine agonists or manta Dean or of the recycling and even allegedly at that point later on with that said, some core morbidity is to keep in mind for individuals who have lower extremity edema, individuals who are prone to Ortho stasis, we tend to be shying away a little bit from the dopamine agonist class. We always screen for dopamine agonist individuals about individuals who might have a tendency towards addictive behavior and addictive personality and because of the risk of developing impulse control issues, which once they occur can be quite significant and quite impairing for folks, many times, individuals don't realize that the impulse control issues are the things that really are related to their medications. They may not necessarily see it that way and the impulse control issues continue to become an issue for them unresolved because they're unaware that this is related to their dopamine ergic medication.