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This question often comes up. Here is a qualitative (literature) study conducted from 1966 to 1999, and was presented in 2002. If anyone has something more current, please post it in replying here. BTW this particular study is pretty comprehensive! It helps explain why my neuro suggests my continued use of selegeline (eldepryl) Peggy The Journal of Family Practice . October 2003 . Vol. 52, No. 10 What is the best initial treatment of Parkinson's disease? EVIDENCE-BASED ANSWER No studies clearly demonstrate the best initial treatment for Parkinson's disease. Levodopa improves motor function in Parkinson's disease; however, long-term use is associated with irreversible dyskinesias and motor fluctuations. Compared with placebo, selegiline improves the motor symptoms of Parkinson's disease and allows a physician to delay the introduction of levodopa by 9 to 12 months (strength of recommendation [SOR]: A, based on randomized controlled trials). Dopamine agonists-alone or combined with levodopa-have fewer associated dyskinesias and other motor complications but produce lower scores on activities of daily living and Unified Parkinson's Disease Rating Scale (UPDRS) when compared with levodopa alone (SOR: A, based on systematic reviews of randomized controlled trials). Drug choices should be based on each patient's individual symptoms and response to medication (Table). EVIDENCE SUMMARY Five randomized controlled trials have shown improved motor function and activities of daily living with selegiline vs placebo in early Parkinson's disease. Two of these trials1, found that selegiline delayed the need for levodopa for 9 to 12 months. One large randomized controlled trial showed no difference in disability scores and an increase in mortality at 5.6 years when comparing selegiline combined with levodopa to levodopa alone. A re-analysis of this study, as well as subsequent studies, have not supported this conclusion and found no increase in mortality in patients with a history of selegiline use. Two Cochrane reviews found that patients who tolerated the dopamine agonist bromocriptine-when administered alone or with levodopa-had delayed dyskinesias and motor complications compared with levodopa alone. There was no change in off-time with the combination. A large randomized controlled trial comparing bromocriptine with levodopa demonstrated that at 3 years, disability scores were lower in the patients initially assigned to bromocriptine, but the difference was no longer significant at 9 years. The bromocriptine group in this trial showed a lower incidence of dyskinesias when data from all patient groups were combined. However, when moderate to severe cases were analyzed separately, there was no significant difference. There was no difference in mortality between patients initially treated with bromocriptine vs levodopa. Studies of other dopamine agonists show results comparable with bromocriptine. Lisuride (not available in the US) with rescue levodopa vs levodopa alone had fewer motor complications at 4 years but lower UPDRS and activities of daily living scores. Another study comparing lisuride (with or without levodopa) vs levodopa alone found no difference in motor complications at 5 years. Studies with cabergoline, pramipexole, and pergolide-alone or combined with levodopa-vs levodopa alone showed a decrease in motor complications with the dopamine agonist but lower activities of daily living and UPDRS scores. RECOMMENDATIONS FROM OTHERS In 2002, the American Academy of Neurology published practice parameters for the initiation of treatment for Parkinson's disease based on literature from 1966 to 1999. The authors concluded: selegiline has mild symptomatic benefit and may be tried as initial therapy, but confers no neuroprotective effect either levodopa or a dopamine agonist can be used for the initial treatment of symptomatic Parkinson's disease levodopa has a higher risk of dyskinesias than a dopamine agonist but superior motor benefits,20 and is less likely to have other side effects (nausea, hallucinations, somnolence, and edema). Jennifer Schreck, MD, Gary Kelsberg, MD, Valley Medical Center Family Practice Residency, Renton, Wash; Joanne Rich, BSc (Pharm), MLIS, University of Washington Health Sciences Libraries, Seattle CLINICAL COMMENTARY Family physicians play a key role in monitoring Parkinson's. Parkinson's disease has a profound impact on a patient's physical and psychological well-being. Difficulties with movement, autonomic nervous system abnormalities, neuropsychiatric symptoms, and problems with medication effectiveness and side effects all occur throughout its course. Consultation with a neurologist skilled in this disorder can be quite helpful, particularly in younger patients or when the diagnosis is unclear. The family physician plays a key role in monitoring of the patient's condition. Active management of symptoms (and comorbidities as they arise) is crucial in helping patients maintain their functional status and quality of life. Randy Ward, MD, Medical College of Wisconsin, Milwaukee ---------------------------------------------------------------------- To sign-off Parkinsn send a message to: mailto:[log in to unmask] In the body of the message put: signoff parkinsn