Parkinson disease
Also known as: parkinsonism · PD
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Dopaminergic Therapy for Motor Symptoms in Early Parkinson Disease
American Academy of Neurology (AAN) · 2021 · 2021 (reaffirmed 2025)
An AAN practice guideline on choosing initial dopaminergic drug therapy for motor symptoms in early Parkinson disease. It compares levodopa, dopamine agonists and MAO-B inhibitors on motor benefit and on adverse effects such as dyskinesia, impulse-control disorders, hallucinations and daytime sleepiness, and considers levodopa formulation choices. Published in Neurology in 2021, endorsed by the Parkinson's Foundation, and reaffirmed in February 2025.
European Academy of Neurology/Movement Disorder Society-European Section Guideline on the Treatment of Parkinson's Disease: I. Invasive Therapies
European Academy of Neurology (EAN) and Movement Disorder Society - European Section (MDS-ES) · 2022 · 2022 (Part I)
The first part of the EAN/MDS-ES guideline series on Parkinson's disease treatment, covering invasive options: deep brain stimulation, lesional procedures, and continuous drug-delivery pump therapies. It applies GRADE to compare these interventions in advanced disease and describes which patient groups they are intended for. Published in 2022 in Movement Disorders and the European Journal of Neurology. A companion part on non-invasive/pharmacological treatment was still in development as of 2025.
- Covers deep brain stimulation, brain lesioning techniques and continuous medication delivery systems using GRADE methodology. source
- Commissioned jointly by the European Academy of Neurology and the MDS European Section. source
- Positioned as Part I of a multi-part European Parkinson's disease guideline series. source
US vs EU key differences
- The two guidelines address opposite ends of the disease course: the 2021 AAN guideline covers initial dopaminergic therapy for motor symptoms in early Parkinson disease, whereas the 2022 EAN/MDS-ES guideline (Part I) covers invasive and device-aided therapies for advanced disease. source
- The US guideline names levodopa as the recommended initial dopaminergic therapy, allowing dopamine agonists only in selected patients under 60 at higher dyskinesia risk, and advising against agonists in patients over 70 or with prior impulse control disorders, cognitive impairment, excessive daytime sleepiness or hallucinations. source
- The European guideline ranks device-aided options: subthalamic nucleus deep brain stimulation carries a strong recommendation for advanced disease with fluctuations (and may be offered in early fluctuations), while levodopa-carbidopa intestinal gel and subcutaneous apomorphine infusion are only conditional options; DBS is recommended against in early disease without fluctuations, and gamma-radiation radiosurgery is not recommended. source
- The European guideline restricts MRI-guided focused ultrasound of the subthalamic nucleus to distinctly unilateral presentations managed within research registries, a caveat that has no counterpart in the US early-disease guideline. source
What changed recently
- EU2013 (EFNS/MDS-ES) → 2022 (Part I)2022-07-06
Replacing the 2013 EFNS/MDS-ES recommendations, this first GRADE-based European guideline covers invasive therapy specifically: subthalamic deep brain stimulation is the best-supported option for advanced disease with fluctuations inadequately controlled on oral drugs and may also be offered when fluctuations appear early, but should not be used in early disease without fluctuations, while levodopa-carbidopa intestinal gel and apomorphine infusion are alternatives and MRI-guided focused ultrasound is restricted to registry use.
source ↗curation confidence 90% - US2002 → 2021 (reaffirmed 2025)2021-11-15
This update of the AAN's 2002 practice parameter on initiating Parkinson treatment re-evaluates levodopa, dopamine agonists and MAO-B inhibitors as initial therapy, concluding that levodopa gives greater motor benefit than dopamine agonists and that although it carries a higher dyskinesia risk, severe or disabling dyskinesia is uncommon in the first five years of treatment.
source ↗curation confidence 90%
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