Grades are shown as the source states them. The guideline words its recommendations by strength: “should” (strong), “can” (intermediate) and “may be considered” (open). Unless a consensus figure is given, each recommendation had more than 90% agreement among the voting experts.
Key recommendations
Diagnose Parkinson's disease using the 2015 International Parkinson and Movement Disorder Society (MDS) clinical criteria. Following the person over several years improves accuracy more than the initial response to levodopa does.
Strong (“should”)Diagnosis: clinical diagnostic criteria
Choose the first drug by weighing efficacy, side effects, age, other illnesses and the person's psychosocial situation, and give levodopa to anyone who needs it.
Strong (“should”)Initial monotherapy
Do not use anticholinergics as antiparkinsonian drugs (unfavourable balance of risk and benefit) except, rarely, for tremor, and do not use ergot-derived dopamine agonists.
Strong (“should”)Pharmacotherapeutic options
Everyone whose motor symptoms affect daily life should have physiotherapy matched to their deficits, at least 3 hours a week (partly as self-training if needed). Offer occupational therapy for difficulties with daily activities or hand function, speech therapy for speech problems and swallowing therapy for dysphagia.
Strong (“should”)Activating procedures; Dysarthria/dysphagia
Favour multidisciplinary inpatient treatment over standard inpatient care. Integrated care in Parkinson's networks with access to specialist nurses, and palliative care through a multidisciplinary team, are recommended.
Strong (“should”)Care concepts
Diagnosis
The guideline prefers the term “Parkinson's disease” to “idiopathic Parkinson syndrome”, because genetic variants and environmental factors contribute in many cases.
Definition
Arrange an MRI brain scan with standardised sequences early in the illness to help separate Parkinson's disease from other parkinsonian syndromes.
Strong (“should”)Imaging diagnostics
Dopamine transporter SPECT can be considered early when a parkinsonian or tremor syndrome is clinically unclear and the result would change management. FDG-PET may be considered when atypical parkinsonism is suspected.
Open; consensus 82.8–84%Imaging diagnostics
Offer genetic testing on request when two first-degree relatives (or one first-degree and one second-degree relative) have Parkinson's disease, or when it began before the age of 50.
Strong (“should”)Genetic diagnostics
Investigations
Diagnose orthostatic hypotension with an active standing (Schellong) test; a tilt-table test, where available, gives fuller information.
Strong (“should”)Orthostatic hypotension
Do not test routinely for polygenic risk or for GBA1 variants. GBA1 testing may be considered, on request and after informed consent, for early onset or rapid motor or cognitive decline.
Genetic diagnostics
Before starting levodopa–carbidopa intestinal gel, screen for neuropathy and check vitamins B6, B12, folate and body weight, and keep monitoring them during treatment.
Strong (“should”)Pump therapies
Treatment
Consider combination therapy when the first drug at an intermediate maintenance dose is not enough, or cannot be increased because of side effects.
Strong (“should”)Combination therapy
For motor fluctuations: adjust levodopa dose and timing, add a different levodopa formulation, or add a dopamine agonist, MAO-B inhibitor or COMT inhibitor, choosing by efficacy, side effects and the person's preference. Use controlled-release levodopa for night-time symptoms only.
Therapy of fluctuations; Pharmacotherapeutic options
Use amantadine to reduce levodopa-induced dyskinesia, watching for its anticholinergic and hallucinogenic side effects.
Strong (“should”)Therapy of dyskinesias
Consider invasive treatment (pump therapy or deep brain stimulation) when levodopa-related fluctuations persist despite optimised oral or transdermal treatment, for example with 5 or more levodopa doses a day, at least 2 hours of off-time a day, or at least 1 hour a day of troublesome dyskinesia. Tell people about these options when fluctuations first appear.
Strong (“should”)Differential indication of invasive procedures
Offer subthalamic deep brain stimulation for fluctuations not controlled by oral treatment, with at least 33% improvement on a standardised levodopa test, taking account of contraindications such as cognitive decline, severe psychiatric symptoms or severe comorbidity.
Strong (“should”)Deep brain stimulation
Treat psychosis step by step: non-drug measures and correction of triggers such as dehydration or infection; then reduce anticholinergic, sedative and other triggering drugs, followed by Parkinson's drugs (amantadine, MAO-B inhibitors, dopamine agonists and COMT inhibitors first). If that fails, offer clozapine after weighing its risks (agranulocytosis, myocarditis, falls, anticholinergic effects), or quetiapine off-label in people without cognitive impairment. With cognitive impairment, a cholinesterase inhibitor can be offered.
Strong (“should”)Psychosis
In Parkinson's disease dementia, offer cognitive stimulation and use rivastigmine; donepezil can be used off-label; do not use galantamine. In mild cognitive impairment, offer cognitive training and aerobic endurance exercise (2–3 sessions a week of 45–60 minutes) but not cholinesterase inhibitors.
Strong (“should”)Cognitive disorders
For depression, optimise dopaminergic treatment (pramipexole if a dopamine agonist is possible) and offer cognitive behavioural therapy and physical activity. Antidepressant choice follows the clinical picture, for example venlafaxine, citalopram or sertraline with lethargy, and mirtazapine (not with REM sleep behaviour disorder) or trazodone with agitation, anxiety or poor sleep.
Affective disorders
Treat orthostatic hypotension in steps: correct triggers such as infection or dehydration; review medicines and reduce or stop antihypertensives; then non-drug measures (adequate fluid and salt unless contraindicated, avoiding large meals, alcohol and heat, sleeping with the upper body raised 10–20°, an abdominal binder in preference to stockings, and muscle-tensing manoeuvres when presyncopal). Midodrine should be used if drugs are needed; fludrocortisone can be used.
Strong (“should”)Orthostatic hypotension
Manage REM sleep behaviour disorder by making the sleeping environment safe; clonazepam and/or melatonin may be considered, bearing their side effects in mind.
Open (“may be considered”)Sleep disorders
For pain, first optimise the Parkinson's medication. Treat nociceptive pain with the WHO analgesic ladder and neuropathic pain preferably with gabapentin and/or duloxetine.
Pain
For an overactive bladder, start with bladder training, spreading fluids through the day and avoiding caffeine, alcohol and fizzy drinks. Antimuscarinics such as solifenacin, trospium or darifenacin can be considered, and mirabegron if these fail or cannot be used.
Bladder dysfunction
Important geriatric considerations
Starting with levodopa brings motor fluctuations and dyskinesia earlier than starting with a dopamine agonist or MAO-B inhibitor, so those are preferred in biologically younger people. Levodopa is the appropriate first choice when symptoms are severe, a quick effect is needed, there is multimorbidity, or side effects of the alternatives are expected.
Initial monotherapy
Before starting a dopamine agonist, warn people about impulse control disorders. Reduce agonists gradually, both to treat these disorders and to recognise dopamine agonist withdrawal syndrome early.
Strong (“should”)Impulse control disorders; Akinetic crisis and withdrawal syndromes
In kidney impairment prefer ropinirole, rotigotine or piribedil to pramipexole, which is cleared mainly by the kidneys; in liver impairment prefer pramipexole. Adjust ropinirole when it is given with CYP1A2 inhibitors or inducers.
Pharmacotherapeutic options: dopamine agonists
Amitriptyline is listed only for depression in people without cognitive impairment, and anticholinergic and sedative drugs are among the first to reduce when psychosis develops.
Affective disorders; Psychosis
Fitness to drive a car needs individual assessment. It is presumed lacking with severe motor impairment, unpredictable fluctuations, or significant cognitive, attentional or visual impairment, and people should not drive for 3 months after deep brain stimulation surgery.
Driving ability
Drug doses
Not covered in this summary — see the original guideline.
When to refer
Specialist Parkinson's day clinics suit people with an unclear parkinsonian syndrome, complex treatment adjustments, or assessment for invasive treatment. Decisions about invasive treatment should be interdisciplinary and involve the patient.
Care concepts; Differential indication of invasive procedures
Pump therapies should be started and continued only by physicians experienced in them, with close monitoring because complications are frequent.
Strong (“should”)Pump therapies
If a genetic cause is still suspected after negative first-line tests and the person wants further investigation, involve a neurogeneticist or clinical geneticist.
Strong (“should”)Genetic diagnostics
Red flags
Akinetic crisis is an emergency: treat early and fully, ideally in intermediate or intensive care. Treat triggers such as infection at once, give fluids, thromboprophylaxis and antipyretics, monitor vital signs, and keep dopaminergic treatment going (soluble levodopa by nasogastric tube, apomorphine, or a rotigotine patch). Consider intravenous amantadine.
Strong (“should”)Akinetic crisis and withdrawal syndromes
Stopping deep brain stimulation (for example a flat battery) can cause a withdrawal syndrome: check the battery every 3–6 months, restore stimulation early, and bridge with the same drug measures as for akinetic crisis.
Strong (“should”)Akinetic crisis and withdrawal syndromes
Clozapine carries risks of agranulocytosis and myocarditis, so weigh them before starting it.
Psychosis
Recent updates
The 2023 revision adopts the MDS diagnostic criteria and the term “Parkinson's disease”, adds guidance on genetic testing and imaging, and covers pump therapies including subcutaneous foslevodopa/foscarbidopa (approved in Europe in 2023, after the consensus conferences, so without a graded recommendation). It is valid until October 2028.
What's new; Pump therapies; Acknowledgements