Considerations in the management of parkinsonism

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Abstract
The current status of levodopa therapy of parkinsonism is discussed. Levodopa does not halt the advance of the pathology underlying parkinsonism, but by improving mobility it delays the onset of fatal complications for several years. It is difficult to identify which late problems are manifestations of parkinsonism seen only because patients survive longer, and which are a direct result of the administration of levodopa. The common early adverse reactions to levodopa were previously defined: anorexia, nausea, vomiting, hypotension, dyskinesia, restlessness, hallucinations and delusions. Late problems of levodopa therapy include rapid and slow fluctuations between severe parkinsonism and dyskinesia (on-off and wearing-off reactions), declining efficacy and deteriorating intellectual performance. Experience with levodopa confirms the value of this drug in parkinsonism, but it also reveals common late adverse reactions, some of which, once established, are difficult to overcome. To delay the onset of such problems, it is becoming common practice to withhold levodopa until the severity of symptoms warrants its use, and then to treat patients with the minimum dose needed to restore adequate motor function. In 5 yr, the extent to which these precautions may have improved the prognosis of patients with parkinsonism can be determined.

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