Once you are confident with the diagnosis of PD, and you determine that pharmacologic therapy is warranted, what kind of clinical decision tree do you rely on to determine your initial, individualized choice for treatment?
So I think that's a very important question. What goes through a Parkinson's specialist mind when they diagnose a patient with Parkinson's disease and both parties, the doctor and the patient and maybe even the caregiver they all feel it is ready to start a symptomatic treatment. I think the benefit of having so many choices for symptomatic treatment also in in a in a weird way is also a disadvantage or the curse because it confuses everyone as to um what to do for what to do next. And we don't really have, we have some consensus criteria are expert consensus on this, but the guidance is not absolute and for good reason because Every patient with Parkinson's disease is affected in a different way. I see 1000 patients with Parkinson's disease in my practice. And in our group we have 5000 patients with Parkinson's disease. And I can tell you that. I don't think I have two patients with an identical regimen with Parkinson's disease. So Parkinson's disease is a very individualized treatment process for the patient and for the clinician. So the first question I think we should ask is this patient warrant treatment, Are they disabled enough? Are they bothered enough with their symptoms to start treatment? If the answer to that is yes, then they should really consider symptomatic treatment. The next question is how bothered are they, are they quite bothered that you need to do something immediately or are they some look bothered and you can test the waters a little bit and. And so that's the next differentiating factors. Um And and the answer to let's say they're quite bothered by it. While the mainstay treatment, the most efficacious treatment to date is levodopa. Um, and it probably has the least side effects of all the medication, pound for pound and it provides the biggest bang for a buck. So if a substantial improvement in their function or their symptoms is required, then levodopa is your go to drug, you probably can't go wrong with that. Now, if the symptoms are mild, but either you want to test whether it is really Parkinson's disease, the patient needs assurance that there will be a symptomatic treatment when they need it. Or they have a mild tremor, but it's not that functional or functionally bothersome, but they're in a profession where they don't want to be noticed with these tremors. So maybe you can start with something milder. An early monotherapy symptomatic treatment other than levodopa. So we have an inhibitor, for example, like residual line that is currently approved for that, you can try a manta Dean, which may be good for tremor resting tremor in Parkinson's disease. If it's somewhere in the middle, it's not, it's a little bit more than a trivial tremor, but not enough to merit levodopa. Maybe you can consider a dopamine agonist, such as pixel or repeatable. Now, the next thing to consider is who the patient is and their tolerance for medications, are they a type of person or a patient that develops side effects very easily if their stomach is not so strong if their GI system is traditionally or historically not the most stable and they easily get nausea. Maybe dopamine agonists. You don't want to try that first as your first drug because it is notorious for gi complications in the beginning. If they're very if they have psychiatric comorbidities and they're on serotonin selective serotonin re uptake inhibitors or norepinephrine reuptake inhibitors. Maybe you don't want to choose residual line, You'd like to avoid residual line or inhibitors in the beginning for the potential drug interaction that might scare your patients. So the side effect profile or the comorbidities of your patient might be another factor to consider. And then there are some practical things to consider, such as finances and drug costs. So some have generic equivalents and others are brand name and have a higher copay. So you have to unfortunately consider all these the co morbidity of your patient, their ability to tolerate medications to pay for the medication, the severity of their illness. Because we have drugs that are really quite efficacious, somewhat efficacious, mildly efficacious. So you want to match the treatment to the severity of their symptoms