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Treatment of Parkinson’s Disease

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The treatment of Parkinson’s disease is symptomatic, and in daily clinical practice it is prescribed based on the functional impact of the symptoms. There are currently no scientifically validated treatments that act on the underlying mechanisms of the disease or alter its progression.

No farmacologic treatment

Health and therapeutic education is crucial throughout the course of the disease. In the early stages, it focuses on psychosocial support for the patient and their environment, as well as planning care and managing advanced disease. In the intermediate and advanced stages, it centers on therapy management, identifying and addressing complications, as well as treatment and end-of-life support.

The patient is advised to follow these recommendations:

Healthy life habits. It is advised to follow a Mediterranean diet and carry out physical and intellectual activities, adapted to each case.

Vitamin supplements. There is no scientific evidence that supports the prescription of vitamin supplements in general. However, some patients may have vitamin deficiencies that can sometimes show symptoms. If this is detected, it is necessary to supplement the vitamin in question. It should always be done under supervision, as some supplements (such as vitamin B6) can interfere with the absorption of the main pharmacological treatment (levodopa).

Nutrition. For patients with autonomic nervous system involvement affecting visceral functions (dysautonomia), if they experience constipation, it is recommended to increase physical activity and follow a high-fiber diet. For those who experience a drop in blood pressure when changing posture (orthostatic hypotension), they are advised to stay well hydrated, follow a salt-enriched diet, or eat frequently in small portions.

Physical activity. It is recommended to engage in daily physical activity (especially walking), taking care not to cause fatigue.

Physiotherapy. Various types of physiotherapy can be beneficial, as they help with common osteotendinous injuries in the disease (such as involvement of the shoulder’s rotator tendons, for example).

Speech therapy. Speech therapy is recommended in patients with speech or swallowing (dysphagia) problems. Thickeners can also help in the management of dysphagia, which in severe cases may require feeding by a gastrostomy tube.

Occupational therapy. It can assist in the functional adaptation of the individual and their environment (home, workplace) to the challenges posed by the symptoms.

Cognitive stimulation. Patients are advised at all stages to maintain an intellectually active life. When cognitive impairment is present—which may appear early on or later in the disease, and can range from mild to dementia comparable to Alzheimer’s disease—patients may benefit from specialized neuropsychological intervention.

Pharmacological treatment

In initial phases, and with no, or very little, functional repercussion, it is recommended not to start a treatment for the symptoms. In this phase, there is the possibility of offering patients to participate in clinical trials with experimental treatments that aim to act on the mechanisms of the disease and modify its course.

The pharmacological treatment acts on the symptoms with variable effectiveness. It is usual to start with low doses, and increase them gradually, in order to ensure tolerance (to avoid nausea, essentially).

There are three large groups for symptomatic treatment:

Dopamine precursors (levodopa in different formulas with different inhibitors of dopa-decarboxylase) to increase its bioavailability.

Dopaminergic receptor agonists (there are different availabilities by oral or transdermal route).

Enzyme inhibitors of levodopa degradation (inhibitors of the monoamine oxidase B (MAO-B) of catechol-O-methyltransferase (COMT) inhibitors).

Treatment is personalized based on the needs of each patient, with continuous monitoring of both its effectiveness and the appearance of potential side effects.

In addition to the scheduled treatment following a fixed dosing routine, there is the option of using rescue therapies when motor fluctuations lead to "off" periods of symptom exacerbation. These may range from an extra dose of standard oral medication (usually an additional dose of oral levodopa) to a single subcutaneous injection of apomorphine (a dopaminergic agonist also used in continuous infusion), sublingual apomorphine (soon to be available), or inhaled levodopa, introduced in recent years.

In the treatment of non-motor symptoms, the following are used:

Laxatives for constipation
Anticholinergics for urinary problems
Medications that raise blood pressure in cases of orthostatic hypotension
Antidepressants for depression and apathy
Acetylcholinesterase inhibitors for cognitive decline and dementia

Drugs for Parkinson's disease

Los fármacos para la enfermedad de ...

Surgical Treatment

If the patient develops complications of refractory motor fluctuations to the pharmacological adjustments, complex therapies are available.

Deep brain stimulation by functional neurosurgery, usually of the subthalamic nucleus.

Continuous drug infusions that work on the premise that a continuous drug infusion avoids or minimises the motor fluctuations.

Continuous infusion of intestinal levodopa gel requires a surgical-endoscopic procedure (insertion of a gastrostomy tube).

Continuous subcutaneous infusion (with an infusion pump similar to that of continuous insulin infusions) of a dopaminergic antagonist (apomorphine).

The three treatments (deep brain stimulation, intestinal infusion of levodopa, and the subcutaneous infusion of apomorphine) are similar in indication and efficacy although with nuances, although there are no comparative studies of the three. Although surgery has its limitation on not being indicated in patients greater than 70 years-old, or with active cognitive or psychiatric anomalies, it appears to be more effective if the patients are well-selected.

Surgical treatment is currently performed in specialist centres and requires an assessment by experts in order to confirm that the patient is a candidate for the treatment. After the surgery is performed, adjustments are made to the stimulator parameters until optimal control of the symptoms is achieved.

Treatment complications

The most common side effects of the drugs are nausea (can be treated to decrease them) and the hallucinations in older patients and/or with previous cognitive impairment.

Levodopa is associated with the so-called chronic complications of treatment, such as motor fluctuations and involuntary generalised or focal movements (dyskinesia) that occur normally after a long-term treatment with levodopa and drugs that increase bioavailability.

The inability to control impulses is currently the most worrying side effect of dopaminergic agonists. These have a 20-30% risk of inability to control impulses (compulsive gambling, hypersexuality, binges, or compulsive shopping), with the highest risk being in young patients with a previous history of addictions.

The nausea, hallucinations, and the hypotension can be produced by all the treatments, but more with agonists than with levodopa. The agonists can also cause swelling (oedema), particularly of the legs, and erythromelalgia (reddening of the skin, oedema, an increase in temperature and pain that increases with the movement and positioning of the limbs, especially the legs) in extreme cases, whilst amantadine can cause livedo reticularis (a symptom that causes a reddish-blue colouring in the skin). The MAO-B inhibitors can severely interact with determined drugs (particularly some antidepressants) in a form of a tyramine reaction, or a serotoninergic syndrome (a group of symptoms caused by an excess of serotonin that affects good humour, sleep, diet, perception of colour, pleasure, and sexual desire).

Serious side effects of the surgery are rare, but might include less than 1% of cases of suffering a cerebral bleeding that is usually the trajectory of inserting the electrodes. There may also be other side effects, such as behavioural changes that require a more detailed control and adjustment of the parameters during the follow-up.

Substantiated information by:

Almudena Sánchez Gómez

Ana Cámara Lorenzo

Maria José Martí Head of the Parkinson's and Movement Disorders Unit

Yaroslau Compta Hirnyj Neurologist Neurology Service

Published: 8 July 2019
Updated: 30 July 2025

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