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Vol. 57 No. 10, October 2000 Letters to the Editor Letter In Reply Weighing the Neurological Complexities of Long-term Levodopa Use I was interested to see the spirited controversy about levodopa "toxicity" in the March issue of the ARCHIVES glad to see the care with which arguments were marshaled on both sides, glad, above all, to see the matter out in the open. When I started giving levodopa to my own patients more than 30 years ago, it became clear that pathological sensitivities and imbalances of all sorts could develop very rapidlythis was especially so in patients with postencephalitic parkinsonism, but they also developed, if more slowly, in patients with idiopathic Parkinson disease. When I tried to draw attention to these effects - commonly dismissed as "side effects" - and to sound a cautious note, there were only reactions of violent disagreement.1 It seemed that rational discussion was scarcely possible at the time. Since the neurological complexities of long-term levodopa treatment are now widely conceded - complexities that may be attenuated but not prevented by concurrent therapy with dopamine receptor agonists, COMT inhibitors, etc - the problems of decision have become sharpened and focused. I would certainly want to be put on levodopa myself, if I became parkinsonian, because nothing else can give comparable benefit. I would want this even knowing that its effects would sooner or later decline and be compromised, and that it might accelerate the disease process or cause neuronal death. The immediate benefit, for me, would outweigh the incalculable future. But others might feel very differently. I think these "economic" (and highly individual) aspects of the decision of when to treat, and how to treat, are an integral part of the issue, and need to be emphasized too. Oliver Sacks, MD 2 Horatio St, 3G New York, NY 10014 1. Sacks OW, Messeloff CR, Schwartz WF. Long-term effects of levodopa in the severely disabled patient. JAMA. 1970;213:2270. MEDLINE In reply Dr Sacks' remarks remind us that indeed, the more things change, the more they remain the same; it is interesting to observe how medical controversies such as the levodopa toxicity debate persist in the face of significant progress in the management of Parkinson disease. It is true that levodopa's adverse effects "may be attenuated but not prevented by concurrent therapy" with adjunctive medications; however, we should not permit the perfect to be the enemy of the good. A reduction in the frequency and severity of motor fluctuations and dyskinesia can have a dramatic impact on the quality of life. Dr Sacks raises an important issue that often is neglected in discussions of Parkinson managementthe importance of making the patient an integral partner in decision-making about levodopa administration. Living well with chronic illness requires an active, involved patient. Our well-intentioned efforts to better understand the risks and benefits of levodopa therapy often eclipse our acknowledgment of the personal nature of decision-making in health care. Although the issues of Parkinson management are complex, we need to find better ways of educating and informing our patients in order to enhance their participation in goal-setting and decision-making. While Dr Sacks would personally choose levodopa therapy for himself, there are patients who would choose significant bradykinesia and rigidity over fluctuations and dyskinesia. Clinical guidelines notwithstanding, one size does not fit all in the management of Parkinson disease. Lisa M. Shulman, MD 425 8th Street NW #645 Washington, DC 20004 (e-mail: [log in to unmask]) 2000 American Medical Association. All rights reserved. http://archneur.ama-assn.org/issues/v57n10/ffull/nlt1000-1.html janet paterson 53 now / 44 dx cd / 43 onset cd / 41 dx pd / 37 onset pd TEL: 613 256 8340 URL: http://www.geocities.com/janet313/ EMAIL: [log in to unmask] SMAIL: PO Box 171 Almonte Ontario K0A 1A0 Canada