Tratamiento de la enfermedad de Parkinson: reserva terapéutica de los agonistas dopaminérgicos

Parkinson's disease (PD) is a neurodegenerative, chronic and progressive disease whose evolutive course changed significantly after the introduction of levodopa. However, no antiparkinsonian drug has been able to stop the progression of PD. Thus, as the years have passed, greater drug doses have been necessary, either alone or in different combinations. Therefore, it is useful to have drugs with a wide threshold between effective dose and maximum tolerated dose. The concept of therapeutic reserve (TR) can be considered equivalent to therapeutic index or therapeutic window and could be defined as the difference between the dose needed to achieve an optimum therapeutic response at a given time and the dose that causes adverse events (maximum recommended dose or «ceiling dose»). This difference indicates the threshold that makes it possible to use higher doses as the disease advances to maintain an optimum clinical effect without the appearance of adverse events. This concept is important in the case of dopaminergic agonists whose efficacy seems to be similar in the daily clinical practice. Although there are no direct comparative studies, the analysis of the results of different studies suggests that the TR of ropinirole is superior to that of other dopaminergic agonists. The first effective dose, defined as an improvement superior to 30% is observed with 9 mg/day in 75% of the patients while the maximum recommended dose is 24 mg/day. This threshold is less with other dopamine agonists.