Slow, Shaky, Stiff: What are the next steps for Family Physicians?
The 2019 Canadian Parkinson Disease (PD) Guidelines were just released this week, with some must-know changes!
POP QUIZ - TRUE / FALSE: The 2019 guidelines now recommend brain imaging for all patients suspected of having idiopathic PD.
Answer is below!
You should know HOW TO MANAGE PD as a Family Physician by doing the following:
1. Determine: Is it PD?
2. Determine: Is it something else?
3. Refer to a specialist to identify TYPE and TREATMENT
4. Refer to allied care*
5. Address additional considerations / nonmotor features**
Bonus (see below):
- Know the PILLS (and PATCH and PEN)
- Know the THINGS TO AVOID
To help you do the above, the 2019 PD guidelines contain 2 helpful tools:
- A new checklist: the MDS Clinical Diagnostic Criteria
- An updated algorithm
POP QUIZ ANSWER: FALSE
A quick glance at the algorithm reveals the answer to the quiz question above is FALSE. Only image & refer if red flags exist. The 10 red flags are listed in detail on the MDS checklist and include
- Bilateral symptoms (PD should be unilateral!)
- Poor treatment response
- early falls
- rapid progression
- marked autonomic or cognitive loss
- see the checklist for more
When ordering imaging, be specific and say which modality and which body part. For example, don't just write MRI... MRI of what body part?
THE PILLS (AND PEN AND PATCH)
Know the medications (and classes) and their roles in PD. The following "may be used as symptomatic treatment in people with early PD":
1. Dopamine Precursor (preferred first-line)
2. Dopamine Agonists (caution in age > 70)
Non-ergot derived (e.g. Pramipexole, Ropinirole, NEW IN 2019 guidelines Rotigotine patch, Apomorphine pen-injector)
Warn about impulse control disorders (gambling, binge eating) in addition to usual side effects
NOTE: the Ergot-derived Dopamine Agonists (eg. bromocriptine) should NOT be used as first-line treatment in early PD as they require monitoring for pulmonary & cardiac fibrosis.
3. MAO inhibitors
THINGS TO AVOID
Avoid using routinely for patients with PD (some are OK to use in clinical trials):
- Avoid abruptly stopping medication and “drug holidays”
- Avoid ALL ANTIPSYCHOTICS except quetiapine and clozapine (needs close monitoring)
- Avoid high-protein diets
- NEW IN 2019: Avoid Amantadine for symptomatic treatment in early PD (insufficient evidence)
- NEW IN 2019: Avoid Genetic testing for monogenetic PD
- NEW IN 2019: Avoid PET scanning
- Avoid Vitamin E
- Avoid Co-enzyme Q10
MORE ON THE ABOVE NEED-TO-KNOW LIST...
Each of these lists would make a great exam question to make sure you know how to manage a patient with PD.
*Refer to allied care such as:
- occupational therapist
- speech language therapy if problems with communication, swallowing, or saliva
- movement disorders clinic if genetic testing requested
- palliative care
**Address additional considerations.
Each one of these has management steps detailed in the guideline:
- Palliative care
- Erectile dysfunction
- Orthostatic hypotension
- REM sleep behaviour