Standard strategies for diagnosis and treatment of patients with newly diagnosed Parkinson disease

The diagnosis of Parkinson disease (PD) is for the most part made by neurologists. A survey performed by an Italian patient association estimated that in Italy about 20% of patients with PD ask for a medical consultation 2 years after onset of symptoms. The delay from first consultation (usually with a general practitioner) to diagnosis is around 5–6 months. Up to 80% of patients are referred to a center specialized in movement disorders, either early in the disease course or later, when motor complications appear. PD is for the most part treated by neurologists and there is insufficient exchange of information between the treating neurologist and the patient's general practitioner.

Some medications can only be reimbursed if prescribed by a National Health System (NHS) specialist based on a written yearly treatment plan. The following drugs for PD and parkinsonian syndromes belong to this category: donepezil, clozapine, quetiapine, rasagiline, and rivastigmine. Patients taking these drugs therefore need to attend at least 1 yearly visit in an NHS specialized center to be granted renewal of treatment plan and reimbursement. Generic drugs are available for products containing levodopa and carbidopa and for oral dopamine agonists, either immediate release or prolonged release. Prescription of generics has been boosted by recent provisions stating that whenever a generic formulation is available it has to be proposed to patients as the first choice. If a generic is available, patients need to pay an additional fee to obtain the branded product.

Specialist visits for the NHS are carried out by NHS doctors during working time with no additional reimbursement and a short allotted time for each visit (around 20 minutes). There is no reimbursement for phone calls or e-mail requests made by the patients: these are usually carried out free of charge by specialist doctors and represent a sizable burden for their activity. The majority of doctors working in teaching and nonteaching hospitals see both NHS and private outpatients. There are no appreciable differences between urban and rural areas. Italy has a high density of urbanization and most patients living in rural areas have easy access to PD specialists in a nearby town.

The diagnosis of PD is clinical and based on the doctor's judgment. Levodopa products are typically used in later disease stages, an attitude shared by doctors and patients, as medical education and patient advocacy groups have repeatedly insisted on the need to delay levodopa prescriptions. Current national guidelines for PD treatment released in 2002 suggest prescribing dopamine agonists as the starting treatment in patients younger than 50 years old and levodopa in patients older than 70. New guidelines are expected to be issued next year. Usually a monoamine oxidase A inhibitor is prescribed as a first drug, followed by a dopamine agonist. Levodopa is typically added at later stages, when there is insufficient motor control. Concurrent prescription of 2 dopamine agonists in a patient is uncommon. A minority of centers prescribe levodopa in patients who have not tried dopamine agonists, also in early disease stages, based on the “oral pulse levodopa strategy” proposed some years ago.1 The Italian Medicines Agency has sponsored a multicenter trial aimed at testing the occurrence of dyskinesias in patients treated with the oral pulse levodopa strategy.

Most patients with PD undergo brain imaging, particularly DAT to confirm dopaminergic denervation and MRI to view brain morphology. DAT scan imaging is more frequently requested by general neurologists than by PD specialists. Clinimetric evaluations are typically based on the motor part of the Unified Parkinson’s Disease Rating Scale (routinely performed only at specialized centers) and on cognitive assessment. Quality of life scales are not used in routine clinical practice.

There are specialized PD centers throughout Italy, with a higher density in Northern regions. Although the frequency of patient monitoring varies among centers, most propose follow-up visits every 6–9 months. Patient management is rather homogeneous throughout the country, also due to several medical educational programs on PD that have been run in recent years.

Correspondence to: alberto.albanese@unicatt.it