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Evidence-Based Assessment of Treatments for Parkinson's Disease

This rigorous, evidence-based review of available treatments for Parkinson's disease should aid specialists and nonspecialists alike.

This excellent report is a summary of a much larger work, from the Movement Disorders Society Evidence Based Assessment Project, in which the authors used modern evidence-based medicine standards to assess the efficacy and safety of available antiparkinsonian therapies. The authors provide conclusions and summarize implications for clinical practice and future research, on the basis of an extensive literature search focusing primarily on reasonably sized, randomized, controlled trials (RCTs) and secondarily on the best clinical evidence available.

The larger work (to be published in Movement Disorders) is divided into sections on specific treatments. In contrast, this review is more problem based, addressing the issues of (1) prevention of Parkinson's disease (PD) progression, (2) control of motor symptoms, (3) management of motor complications, and (4) treatment of nonmotor symptoms. Available therapies are rated as "efficacious," "likely efficacious," or "insufficient evidence." The goal was "to improve clinicians' knowledge of the presently available published clinical evidence, based mainly on randomized controlled trials," rather than to define practice guidelines or treatment algorithms. In addition to providing important insights into available treatments, this work points out major deficiencies in the literature. For example, evidence is lacking regarding the efficacy of routine interventions (e.g., rehabilitation; treatment of depression, dementia, and dysautonomia), and there have been few comparisons among available treatment options.

Comment: This extremely useful summary of the published clinical evidence supports various therapeutic interventions for PD. In contrast to recently published practice parameters (Neurology 2002; 58:11), which have focused solely on initiation of treatment in early PD, this review covers all available treatments used at all stages of the illness. Unlike other recently published treatment algorithms developed by small panels of experts, this report summarizes a rigorous and transparent evidence-based approach to the pertinent literature. The authors appropriately acknowledge their methodologic limitations, including the concentration on RCTs (which emphasize more recently marketed drugs) and closure of the database at January 2001 (which excluded more recent reports that assess imaging of the nigrostriatal dopamine system in comparative studies of dopamine agonists versus levodopa). Nonspecialists should find this review extremely helpful. Specialists in PD management will still find it useful, particularly the emphasis on lacunae that exist in this treatment literature.

— Anthony E. Lang, MD

Dr. Lang is Director, Movement Disorders Clinic, Toronto Western Hospital, and Jack Clark Chair for Parkinson's Disease Research, University of Toronto, Canada.

Published in Journal Watch Neurology July 25, 2002

Citation(s):

Rascol O et al. Treatment interventions for Parkinson's disease: An evidence based assessment. Lancet 2002 May 4; 359:1589-98.

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