Parkinsonian Drugs: Guidelines for Japan

Abstract

Drugs for Parkinson’s disease (PD) permitted by the Department of Health, Labor and Welfare in Japan now (as of October, 2017) includes L-dopa, L-dopa/DCI (dopa decarboxylase inhibitor), L-dopa/DCI for intra-jejunal injection, dopamine agonists (bromocriptine, pergolide, cabergoline, pramipexole, ropinirole, rotigotine, and apomorphine), selegiline, entacapone, zonisamide, istradefylline, amantadine, anti-cholinergics (trihexyphenidyl and others), and droxidopa. The first guideline for PD was published in 2003. It was revised in 2011 and 2018. In the edition, newer drugs such as rotigotine, apomorphine, and istradefylline have been added. As the third version was not published when this version was completed, the second edition was adopted. The Guideline Committee reviewed vast numbers of articles since 1983 until September, 2008. In the second guideline, clinical efficacy and safety of each anti-PD drug was described. The evidence level adopted was that of Minds treatment guidelines as follows: I; conclusions obtained by the systematic review or the meta-analysis of the randomized control trials (RCT), and II, III, IV, V, VI with decreasing confidence. In the second part of the revised guideline, 42 clinical questions such as “When anti- PD drugs should be started for PD?" were raised and the recommendations of the Guideline Committee were added according to the Minds degree of probability for each question as follows: A; strong scientific evidences are present and it is strongly to follow their recommendations, B, C, D with decreasing confidence. The Guideline Committee made the conclusion as efficacious and safe or probably safe in all of the anti-PD drugs listed above. But for the ergot dopamine agonists, the Committee was the opinion that they should not be used as the first-line treatment.