To review the current evidence on the options available for initiating dopaminergic treatment of motor symptoms in early-stage Parkinson disease and provide recommendations to clinicians.
A multidisciplinary panel developed practice recommendations, integrating findings from a systematic review and following an Institute of Medicine-compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence.
Initial treatment with levodopa provides superior motor benefit compared to treatment with dopamine agonists, whereas levodopa is more likely than dopamine agonists to cause dyskinesia. The comparison of different formulations of dopamine agonists yielded little evidence that any one formulation or method of administration is superior. Long-acting forms of levodopa and levodopa with entacapone do not appear to differ in efficacy from immediate-release levodopa for motor symptoms in early disease. There is a higher risk of impulse control disorders associated with the use of dopamine agonists than levodopa. Recommendations on initial therapy for motor symptoms are provided to assist the clinician and patient in choosing between treatment options and to guide counseling, prescribing, and monitoring of efficacy and safety.

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BACKGROUND: This study examines the links among diabetes, tardive dyskinesia (TD), and other extrapyramidal symptoms (EPS) in schizophrenia outpatients treated with typical and atypical antipsychotics.
OBJECTIVE: Using a retrospective chart review, we compared 30 schizophrenia patients with diabetes mellitus (DM) with 30 schizophrenia patients, matched for age and sex, with no DM. We compared prevalence and severity of parkinsonism, akathisia, TD, dystonia, and antipsychotic type (that is, typical vs atypical).
RESULTS: We found no statistically significant differences between the DM group and the non-DM group prevalence and severity of EPS, including TD.
CONCLUSIONS: We did not find DM and TD association to be significant in the era of atypical antipsychotics, possibly because of their antidyskinetic effect.

OBJECTIVE: The objective of this paper is to integrate what is known about estrogen effects on symptoms and treatment response into a global understanding of schizophrenia. The aim is to expand Canadian schizophrenia guidelines to include the specific needs of women.
METHODS: We searched the Medline database; keywords included estrogen, estrogen replacement therapy, schizophrenia, psychosis, treatment, tardive dyskinesia (TD), and women. We examined reference lists from relevant articles to ensure that our review was complete. We review the evidence for the effects of estrogen in schizophrenia and we make recommendations for the next revision of official practice guidelines.
RESULTS: The epidemiologic evidence suggests that, relative to men, women show an initial delay in onset age of schizophrenia, with a second onset peak after age 44 years. This points to a protective effect of estrogen, confirming animal research that has documented both neurotrophic and neuromodulatory effects. Clinical research results indicate that symptoms in women frequently vary with the menstrual cycle, worsening during low estrogen phases. Pregnancy is often, though not always, a less symptomatic time for women, but relapses are frequent postpartum. Some work suggests that in the younger age groups women require lower antipsychotic dosages than men but that following menopause they require higher dosages. Estrogen has been used effectively as an adjunctive treatment in women with schizophrenia. Estrogen may also play a preventive role in TD.
CONCLUSIONS: Symptom evaluation and diagnosis in women needs to take hormonal status into account. Consideration should be given to cycle-modulated neuroleptic dosing and to careful titration during pregnancy, postpartum, and at menopause. We recommend that discretionary use of newer neuroleptic medication and adjuvant estrogen therapy be considered.

BACKGROUND: This article describes a specialist\'s perspective on the challenge of caring for patients with Parkinson disease in a changing American health care environment that places increasing responsibility on primary care physicians.
METHODS: Guidelines were developed by drawing from a combination of personal experience at a large university Parkinson disease clinic, literature review, presentations at various family practice continuing medical education conferences, and involvement as investigator in various clinical trials of drugs used in Parkinson disease treatment.
CONCLUSIONS: From a therapeutic standpoint, Parkinson disease can be divided into three stages--early, nonfluctuating, and fluctuating. Although the same drugs, namely, carbidopa-levodopa preparations, dopamine agonists, and anticholinergic medications, are usually prescribed, their pattern of use, including frequency and dosing, varies depending on the nature of the dominant symptoms and stage of the disease. Management of Parkinson disease requires familiarity with both the disease-related and drug-related components. Optimal functional efficiency for the patient is gained through striking a delicate balance between the drug regimen and the disease-related components.

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Despite increasing public and legal pressures to minimize the occurrence of tardive dyskinesia, the practicing clinician often feels there are no alternatives to the use of neuroleptic medication in the treatment of psychosis. However, there are many clinical situations in which the use of neuroleptics may be avoided; guidelines for such situations, including the treatment of affective disorders and of chronic schizophrenia, are presented. The authors also discuss the use of alternative treatment programs and psychosocial interventions that may allow significant reduction in neuroleptics, and they describe new areas of research aimed at preventing and treating tardive dyskinesia.

In neuroleptic maintenance therapy, first-illness schizophrenic patients should be prescribed continuing medication for at least one year. In the management of chronic schizophrenic patients following relapse, neuroleptic medication in standard oral doses or depot injections is recommended for periods in excess of 5 years to reduce the risk of relapse. Results are summarized from studies regarding drug therapy in conjunction with psychotherapeutic factors and family environment, the efficacy of lower dosage, benefit/risk ratios, and the advantages of long-term neuroleptic maintenance. The relationships of neuroleptic dose to plasma level and to therapeutic response are considered, as well as the implications of polypharmacy (e.g., use of anticholinergic drugs with neuroleptics).

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