A large proportion of all Parkinson’s patients
develop motor fluctuations and dyskinesias following some years of peroral
levodopa therapy. About 50% of older and
90% of younger patients have such difficulties after five years of therapy. Initially, these difficulties can be
counteracted by modifications of the peroral therapy. This might include fragmentation of levodopa
doses, as well as the addition of dopamine agonists, catechol-O-methyl
transferase (COMT) inhibitors and monoamine oxidase B (MAO-B) inhibitors. After some years of treatment, a proportion of the patients cannot be adequately controlled by peroral therapy only. It has been estimated that this concerns 10-20% of the Parkinson's population. For these patients there are now four advanced therapy opportunities that can improve the symptomatology and their quality of life: subcutaneous apomorphine injections with injection pens, subcutaneous apomorphine infusion with portable pump, intraduodenal levodopa/carbidopa infusion with portable pumps, and deep brain stimulation (DBS) – mostly performed in the subthalamic nucleus (STN).
The apomorphine injections are given on demand on top of a peroral therapy. The injections are used to interrupt unwanted “off” periods. The infusion treatments are based on the principle of a continuous dopaminergic stimulation and are given either as monotherapy (levodopa/carbidopa infusion) or combined with a reduced peroral therapy. They can considerably reduce the time with Parkinson’s symptoms (“off” periods), as well as the dyskinesias. It is important to know for each patient when these therapies can offer an opportunity for better symptom control. In the following, we summarise the indications and contraindications for the advanced therapies. The clinically most relevant indications and contraindications are listed. (For a complete listing we refer to the respective product information/declarations).
Professor P. Odin, Bremerhaven, Germany
