Dopaminergic treatment of non-motor Parkinson's disease symptoms
J. EricAhlskog, Clinical neurologist, Mayo Clinic, Rochester, MNeahlskog@Mayo.edu
J. Eric Ahlskog
Submitted March 20, 2013
Drs. Antonini and Albin [1] highlighted an important issue for Parkinson's disease patients: treatment of not only motor, but certain non-motor symptoms. The referenced paper by Storch and colleagues [2] illustrated the fact that many of these non-motor symptoms have a dopaminergic substrate or contribution.
Although I appreciate the attention paid me in their editorial1, the paper I published in NEUROLOGY that they discussed [3] , focused on the untreatable or poorly-treatable burden of non-dopaminergic problems afflicting advancing Parkinson's disease, both motor and non-motor. Three problems were emphasized in that paper3: "levodopa-refractory motor symptoms, dementia and dysautonomia". The important distinction in that article was between dopaminergic and non-dopaminergic, not motor versus
non-motor. It is well-recognized that many PD non-motor symptoms are
levodopa-responsive, and books addressing PD treatment thoroughly address levodopa treatment of non-motor symptoms such as anxiety, insomnia, pain, urinary frequency and akathisia [4-6]. Hence, "non-motor" should not be conflated with "non-dopaminergic".
One additional point is worth mentioning, reiterating from the editorial of Antonini and Albin1: "...optimizing dopaminergic therapies is a viable avenue to improve control of some disabling non-motor symptoms in PD and a worthwhile area for further clinical research." Lest we forget, we have levodopa therapy, which in my experience from referred patients, is often "saved for later" and when prescribed, is administered in very conservative doses. Unfortunately, "levodopa phobia"7 persists. The non- motor problems highlighted in the paper by Storch and colleagues2 should all benefit from medication adjustments and most importantly, optimizing levodopa therapy.
References
1. Antonini A, Albin RL. Dopaminergic treatment ad nonmotor features
of Parkinson's disease Neurology 2013;80:784-785.
2. Storch A, Schneider CB, Wolz M, et al. Nonmotor fluctuations in
Parkinson's disease Neurology 2013;80:800-809.
3. Ahlskog JE. Beating a dead horse. Dopamine and Parkinson's disease.
Neurology 2007;69:1701-1711.
4. Ahlskog JE. The Parkinson's Disease Treatment Book: Partnering with
Your Doctor to Get the Most from Your Medications. New York, NY: Oxford University Press, 2005.
5. Ahlskog JE. Parkinson's Disease Treatment Guide for Physicians. New
York, NY: Oxford University Press, 2009.
6. Ahlskog JE. Dementia with Lewy Bodies or Parkinson's. Patient, family
and clinician working together for better outcomes. New York, NY: Oxford University Press, 2013; in press.
7. Kurlan R. "Levodopa phobia": A new iatrogenic cause of disability in
Parkinson's disease. Neurology 2005;64:923-924.
Drs. Antonini and Albin [1] highlighted an important issue for Parkinson's disease patients: treatment of not only motor, but certain non-motor symptoms. The referenced paper by Storch and colleagues [2] illustrated the fact that many of these non-motor symptoms have a dopaminergic substrate or contribution.
Although I appreciate the attention paid me in their editorial1, the paper I published in NEUROLOGY that they discussed [3] , focused on the untreatable or poorly-treatable burden of non-dopaminergic problems afflicting advancing Parkinson's disease, both motor and non-motor. Three problems were emphasized in that paper3: "levodopa-refractory motor symptoms, dementia and dysautonomia". The important distinction in that article was between dopaminergic and non-dopaminergic, not motor versus non-motor. It is well-recognized that many PD non-motor symptoms are levodopa-responsive, and books addressing PD treatment thoroughly address levodopa treatment of non-motor symptoms such as anxiety, insomnia, pain, urinary frequency and akathisia [4-6]. Hence, "non-motor" should not be conflated with "non-dopaminergic".
One additional point is worth mentioning, reiterating from the editorial of Antonini and Albin1: "...optimizing dopaminergic therapies is a viable avenue to improve control of some disabling non-motor symptoms in PD and a worthwhile area for further clinical research." Lest we forget, we have levodopa therapy, which in my experience from referred patients, is often "saved for later" and when prescribed, is administered in very conservative doses. Unfortunately, "levodopa phobia"7 persists. The non- motor problems highlighted in the paper by Storch and colleagues2 should all benefit from medication adjustments and most importantly, optimizing levodopa therapy.
References
1. Antonini A, Albin RL. Dopaminergic treatment ad nonmotor features of Parkinson's disease Neurology 2013;80:784-785. 2. Storch A, Schneider CB, Wolz M, et al. Nonmotor fluctuations in Parkinson's disease Neurology 2013;80:800-809. 3. Ahlskog JE. Beating a dead horse. Dopamine and Parkinson's disease. Neurology 2007;69:1701-1711. 4. Ahlskog JE. The Parkinson's Disease Treatment Book: Partnering with Your Doctor to Get the Most from Your Medications. New York, NY: Oxford University Press, 2005. 5. Ahlskog JE. Parkinson's Disease Treatment Guide for Physicians. New York, NY: Oxford University Press, 2009. 6. Ahlskog JE. Dementia with Lewy Bodies or Parkinson's. Patient, family and clinician working together for better outcomes. New York, NY: Oxford University Press, 2013; in press. 7. Kurlan R. "Levodopa phobia": A new iatrogenic cause of disability in Parkinson's disease. Neurology 2005;64:923-924.