46M with tremor-predominant Parkinson's disease, newly diagnosed. MDS-UPDRS Part III score 28. Tremor is predominantly right-hand, mildly affecting his work as a software engineer. MRI brain normal. DAT scan confirms nigrostriatal dopaminergic deficit. He is young-onset PD (<50 years). AAN and MDS guidelines differ on whether to start levodopa/carbidopa or a dopamine agonist (pramipexole/ropinirole) first in young patients. What are the risks of early levodopa (motor fluctuations, dyskinesias) vs dopamine agonist (impulse control disorders, daytime somnolence) in this demographic? Should he also start an MAO-B inhibitor (rasagiline)?
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