Most people with Parkinson's start on tablets. Levodopa is usually first choice when symptoms affect daily life. Dopamine agonists and MAO-B inhibitors are alternatives in early disease. As Parkinson's progresses and tablets wear off between doses, doctors add other medicines, such as COMT inhibitors.
For advanced Parkinson's that tablets no longer control, options include apomorphine, a continuous levodopa pump under the skin (foslevodopa–foscarbidopa) and deep brain stimulation (DBS). DBS is available in Ireland through a national service at the Mater and Beaumont hospitals in Dublin. Focused ultrasound is approved in the US but, in England, NICE says it should only be used in research for Parkinson's.
None of these treatments slows the disease itself. They treat symptoms, often very effectively.
Our article on why Parkinson's has good symptom control but nothing that slows it explains the biology and the evidence on newer add-on drugs and exercise. If you are still unsure whether a tremor is Parkinson's, see essential tremor or Parkinson's and our guide to slow movement and stiffness.
This page is about the treatment pathway itself, and what is available in Ireland and the UK.
NICE guideline NG71 says to offer levodopa to people in the early stages whose motor symptoms affect their quality of life. If symptoms do not yet affect quality of life, it says to consider a choice of levodopa, a dopamine agonist or an MAO-B inhibitor.
NICE sets out the trade-offs:
NICE also warns that Parkinson's medicines should never be stopped suddenly. Stopping abruptly, or missing doses because of vomiting or surgery, risks severe immobility or a dangerous reaction called neuroleptic malignant syndrome. If you are admitted to hospital, make sure staff know your medicine times.
Dopamine agonists can trigger impulse control disorders. These include compulsive gambling, hypersexuality, binge eating and compulsive shopping. People affected may hide them.
In a study of 3,090 people with Parkinson's in the US and Canada, 13.6% had an impulse control disorder. They were more common in people taking a dopamine agonist (17.1%) than in those who were not (6.9%).
NICE says:
If you notice new compulsive behaviour in yourself or someone you care for, tell the Parkinson's team. Do not stop the medicine suddenly on your own.
NICE says people with daytime sleepiness or sudden onset of sleep should not drive, and should think about risks at work. Its guidance mentions the DVLA. In Ireland, our guide to driving with a neurological condition explains the rules.
After some years, many people notice "wearing off" before the next dose, or involuntary movements (dyskinesia) at peak dose. NICE says to get specialist advice before changing treatment.
For these motor fluctuations, NICE says to offer a choice of add-on medicines alongside levodopa:
If dyskinesia is a problem despite adjusting medicines, NICE says to consider amantadine. It says not to offer anticholinergics to people with fluctuations or dyskinesia.
When symptoms are no longer controlled by the best tablet regime, NICE describes three main routes.
NICE says best medical therapy for advanced Parkinson's may include intermittent apomorphine injections or a continuous apomorphine infusion under the skin.
This is levodopa in a form that can be pumped continuously under the skin, 24 hours a day, through a small cannula, according to its UK product information.
In the main phase 3 trial, 141 people with advanced Parkinson's were randomised to the pump or to standard oral levodopa, in a double-blind design. Good "on" time, without troublesome dyskinesia, rose by 2.72 hours a day with the pump and 0.97 hours with tablets, a difference of 1.75 hours. "Off" time fell by 1.79 hours more with the pump.
Side effects were common. Adverse events occurred in 85% on the pump and 63% on tablets. The most frequent were infusion-site problems: redness (27%), pain (26%), cellulitis (19%) and swelling (12%). Serious adverse events were similar (8% vs 6%). The trial was funded by the manufacturer, AbbVie.
NICE TA934 (November 2023) recommends it for advanced Parkinson's with severe fluctuations and dyskinesia, only if apomorphine or DBS is unsuitable or no longer works.
Older options that deliver levodopa gel into the gut through a tube are also used. NICE refers to NHS England's commissioning policy for these.
DBS involves surgery to place thin electrodes in a specific part of the brain. They are connected to a pacemaker-like device under the skin of the chest, which sends small electrical pulses.
NICE says DBS should be considered for advanced Parkinson's that is not adequately controlled by best medical therapy, and not offered if medicines already control symptoms. Its procedure guidance says the evidence supports use with normal arrangements for consent and audit. Patients should be selected by a multidisciplinary team.
The UK's PD SURG trial randomised 366 people with advanced Parkinson's to DBS plus medicines or medicines alone. At one year, quality of life scores improved by 5.0 points with surgery and 0.3 points without, a difference of 4.7 points. Mobility, daily activities and bodily discomfort improved. Other quality of life domains did not differ significantly.
The risks are real. In PD SURG, 19% of surgery patients had serious surgery-related adverse events, and there was one procedure-related death.
MRI-guided focused ultrasound uses beams of ultrasound, aimed through the skull, to create a tiny lesion in a target area of the brain. There is no implant and no incision.
In the US, the FDA has approved the Exablate system for one-sided treatment of tremor-dominant Parkinson's (December 2018) and of advanced Parkinson's with motor complications (October 2021), according to its device records.
NICE is more cautious. In December 2024 it said that both focused ultrasound thalamotomy for Parkinson's tremor and focused ultrasound subthalamotomy for Parkinson's should only be done in formal research studies. It noted there is little good-quality evidence, mainly from observational studies and one small randomised trial.
Our essential tremor page covers focused ultrasound for essential tremor, where the evidence is different.
US status, for context: foslevodopa–foscarbidopa (as Vyalev) was approved by the FDA in October 2024, according to Drugs@FDA.
The NCPE recommended in March 2023 that foslevodopa–foscarbidopa not be reimbursed at the price submitted. The HSE then approved reimbursement in March 2024, after confidential negotiations.
Before late 2021, Irish patients needing DBS had to travel to the UK. According to UCD, the National DBS Service is based at the Mater Hospital in partnership with Beaumont Hospital, where surgery is performed. Patients are selected by a specialist team at the Mater, and the device is programmed at the Dublin Neurological Institute.
In October 2022, the Medical Independent reported that 20 implant surgeries had been done in the first year, 16 of them for Parkinson's. The lead surgeon said theatre access limited capacity, and that some patients still went to the UK. We could not find more recent activity or waiting-time figures.
Referral to DBS goes through your neurologist. Our guide to getting referred to a neurologist in Ireland explains the first step.
We did not check separate decisions.
We have not listed trials. Ask your Parkinson's team if you are interested in research. A trial is research, not a treatment option.
Depression is common in Parkinson's. If you or someone you care for has thoughts of suicide, call Samaritans free on 116 123 in Ireland or the UK, or text 50808 in Ireland. In an emergency, call 112 or 999.
Not always. NICE says to offer levodopa when motor symptoms affect quality of life. If they do not, a dopamine agonist or MAO-B inhibitor is also an option. Each has trade-offs.
Yes. A national DBS service, based at the Mater with surgery at Beaumont, has operated since late 2021. It is for selected people whose symptoms are not controlled by medicines. Ask your neurologist about referral.
It is approved in the US. In England, NICE says it should only be used in research studies for Parkinson's. We found no public HSE service in Ireland.
No. They treat symptoms, sometimes dramatically. No treatment has been shown to slow the disease.
This article is general information, not medical advice. Talk to your GP or Parkinson's team about your own situation.
Reviewed by: Proco Team
Last updated: November 2026