Mr Brown is 57 years old, has been a professional actor since he was 21 and works at a theatre. His wife Amanda, 54, works part-time as a secretary. They have a son David, 19, living at home and a small house in a suburban area.
Mr Brown developed the first signs of Parkinson’s disease when he was 45, noticing that his right arm worked less well and he also had difficulties with fine motor functions like writing, as well as shoulder pain.
After visits to a general practitioner, orthopaedic surgeon and finally a neurologist he received the Parkinson’s diagnosis one year after the first symptoms began to appear. Levodopa therapy was started, with excellent effect and during the first three years Mr Brown could almost forget that he had Parkinson’s, as long as he took his medicine.
After three years the first problems began to appear. Mr Brown, who was now taking three doses of levodopa-benserazide 100/25 daily, noticed the symptoms late at night and early morning. He also noticed there were gaps when the medication was effective during the day, starting one to two hours before it was time for the next dose. The neurologist increased the number of levodopa doses and added entacapone to each levodopa dose. This solved the situation for approximately one year. The medication had to be modified again: a dopamine agonist (cabergoline) was added, also selegiline, but in spite of these changes the fluctuations partly remained. Mr Brown was referred to the movement disorder clinic at the university hospital. Mr Brown was admitted into the neurology ward for ten days to optimise Parkinson’s therapy and received the following medication: levodopa-benserazide 100/25 six doses per day, cabergoline 6 mg once daily, entacapone 200 mg six doses per day, and selegiline 10 mg once daily. He was also instructed to take one tablet of soluble levodopa-benserazide 100/25 on demand when needed. The changes in medication led to a clear improvement in clinical status, but after six months fluctuations in motor function became troublesome.
At this stage Mr Brown (now 50) experienced sudden “off” periods three to five times per day. When “off” he could not walk at all and had clear difficulties with his hand motor functions. Soluble levodopa was effective but only after 40 minutes. He had no dyskinesias and his cognitive functions were normal. Mr Brown was experiencing work difficulties – sudden “off” periods made it virtually impossible for him to participate in plays. The theatre had given him other, less stimulating duties and he was on 50% sick-leave for nine months, resulting in discussions as to whether or not he should stop working completely.
The university neurologist thought that apomorphine injections on demand would be a good option and Mr Brown was again admitted to the neurology ward. Apomorphine tests were carried out with 3 mg injections with clear and good effect. Apomorphine pen treatment was initiated and Mr Brown was instructed to take an injection of 3 mg of apomorphine as soon as an “off” period appeared during normal peroral therapy. This worked excellently. In nine cases out of 10 Mr Brown gained the full effect of apomorphine injections and after a mean of six to seven minutes he experienced normal motor functions again. In those cases where a good effect after the first injection was not evident, Mr Brown took a second injection 15 minutes after the first injection. In this way he could eliminate virtually all “off” periods.
Thanks to his treatment Mr Brown was able to return to working full-time and was able to participate in theatre performances. When he felt that an “off” period was coming he quickly took an injection and could continue with his activities without any interruption. The apomorphine injections led to improved control over the symptomatology, which in turn led to better self confidence and improved possibilities for living a normal life. Mr Brown started playing golf again and reinstated other parts of his social life.
Before apomorphine Mr Brown had spent a mean of two and a half hours “off” per day; when using apomorphine the “off” time was reduced to a mean of half an hour. There was a strong improvement of health-related quality of life, as documented with the PDQ-39 scale at the university neurology department.
The effect of apomorphine injections has remained stable for the last five years. Regarding peroral treatment only minor changes have been necessary. Mr Brown is still working full time. Health-related quality of life remains stable. Mr Brown uses a mean of four and a half injections of apomorphine per day. His peroral medication is now: levodopa-benserazide/entacapone 100/25/200 six doses per day, ropinirole ER 16 mg once daily and selegiline 10 mg once daily.
(This report is based on a real life patient’s case history, with some details being modified.)
