The 2017 Parkinson's disease NICE Guidelines: What's new, what's in, and what's out

Professor Richard Walker – Consultant Geriatrician, Northumbria Healthcare NHS Foundation Trust, and Honorary Professor of Ageing and International Health, Institute of Health and Society, Newcastle University.

I have had a long standing involvement in Parkinson’s disease (PD) from a clinical and research perspective and am consultant lead for the UK Parkinson’s Excellence Network, as well as PD research lead for north-east DeNDRoN.  I have also had a long standing interest in sub-Saharan Africa, and in particular, Tanzania, with research in non-communicable disease mainly relating to neurology, and am Associate International Director for sub-Saharan Africa for the Royal College of Physicians.

The first NICE guidelines for Parkinson’s disease (PD) were published in 2006 and have had a big influence on both the management of PD and the development of multidisciplinary services for PD since.  For example, they stated that people with Parkinson’s (PwP) should have access to specialist physiotherapy and this has been very helpful when trying to obtain funding for specialist physiotherapy input. However, there have been significant developments in certain areas of PD practice since 2006 and the current update is therefore timely. 

I was one of two geriatricians with an interest in PD on the update committee which started meeting in October 2014. A scoping committee in August 2014 defined the areas that needed updating and the new areas that we would look at, while areas such as “All people with suspected PD should be referred to a specialist service” remained in place from 2006.  The guidelines were finalised in April 2017 and published last summer.  I was also involved with the Quality Standard Advisory Committee which agreed 5 quality standards based on the NICE guidelines, which were published at the end of 2017.

In terms of drug treatment there was reassurance that levodopa is a very effective symptomatic treatment and would be the first choice drug treatment in the  majority of individuals but there is also a place for dopamine agonists, monoamine oxidase type B inhibitors and catechol-O-methyl transferase inhibitors as previously. 

One new area that has become more apparent since 2006 is impulse control disorders which are a particular problem with dopamine agonists but can occur with any dopaminergic treatment. Patients, and their families (this is particularly important as patients may lack insight into the problems), should be warned about this and this needs to be documented.

Clonazepam or Melatonin can be considered for the treatment of REM sleep behaviour disorder, a common problem for PwP. Orthostatic hypotension is also a common problem and when adjustments of other potential pharmacological and non-pharmacological interventions have been undertaken. Midodrine can be considered, taking into account the contraindications and monitoring requirements. Fludrocortisone, one of the most common treatments used in clinical practice, may also be considered, though it is not licensed for this indication. 

Quetiapine can be considered for treatment of hallucinations and delusions, having taken into account other precipitating factors for delirium, and potentially decreasing culprit dopaminergic medication, but Clozapine should be “offered” as this is the drug for which there is the strongest evidence.  However, this is a difficult drug to use as regular blood monitoring is required and many places do not have access to a monitoring service.  This is one of the 5 quality standards and I think will be difficult for many services to meet. 

A very helpful update is that cholinesterase inhibitors should be offered for mild to moderate PD dementia (Rivastigmine is the only one licensed) and that Memantine, which is increasingly being used for this indication, may be considered.

Drooling, due to decrease in the triggering for automatic swallows, is also a major problem for PwP, particularly when they are concentrating on other things.  Both glycopyrronium  bromide (routinely used in palliative care) and botulinum toxin A can be considered though neither are licensed. 

There has been a massive increase in research into physiotherapy and physical activity since 2006 and there is now a recommendation to refer to physiotherapy in the early stages and to provide information about physical activity.  In view of the high prevalence of vitamin D deficiency, the frequency of falls and consequent fractures, vitamin D supplements are recommended. Early referral should also be considered for occupational therapy and speech and language therapy and, as for physiotherapy, PwP should be referred as and when for relevant problems.  There is mention of the importance of palliative care and consideration of advance care planning although evidence in this area is limited. 

The most contentious component of the guidelines was that while deep brain stimulation (DBS) was found to be cost-effective for people with advanced PD whose symptoms were not adequately controlled by best medical therapy levodopa-carbidopa intestinal gel (duo-dopa), while effective, did not meet the cost-effectiveness threshold for NICE due to its expense.  There is continued debate about this and currently PwP can still be referred for duo-dopa. 

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