Parkinson's Disease: Who Gets Advanced Therapies?
Parkinson's Disease: Who Gets Advanced Therapies?
Levodopa-induced motor complications of Parkinson's disease, including motor fluctuations and dyskinesias, become increasingly frequent as the disease progresses, and are often disabling. Oral and transdermal therapies have limited efficacy in controlling these problems. Advanced device-aided therapies, including continuous infusion of apomorphine, deep brain stimulation and levodopa-carbidopa intestinal gel can all ameliorate these complications. This review summarises the principles of each of these therapies, their modes of action, efficacy and adverse effects, and gives advice on timely identification of suitable patients and how to decide on the most appropriate therapy for a given patient.
When appointed as a consultant neurologist in 2004, I set up a movement disorder clinic. Things seemed easy at first—I confidently diagnosed new patients with Parkinson's disease and started them on what I thought was the right treatment. Most responded and both they and I were pleased.
Eight years on, things are a bit different. I have learnt great respect for the principle that no two patients with Parkinson's disease are the same. Indeed, a few patients I diagnosed with Parkinson's turned out not to have it, a few others who did have Parkinson's have died, a few more have become demented and are in care homes, and still more have developed motor complications of levodopa therapy. Some of the motor complications are severe and have become resistant to medication tinkering. Some have gone on to receive one of the three main so-called 'advanced therapies':
Some patients have done well, others less so. Did I make the right choices? I am interested in how to select patients for these. All are expensive, and not all are suitable for all advanced patients, and each can have serious complications. However, when you get it right, they can be life changing.
Geriatricians manage more patients with Parkinson's disease than neurologists in the UK, and there are wide variations in access to and experience of each treatment. Identifying patients who may benefit may be more difficult for a general neurologist in a busy general clinic than for a movement disorder neurologist in a tertiary specialist clinic. Some patients are referred much too late and others never get the opportunity. Therefore, my main aim is to help the generalist identify suitable patients for timely referral.
I will discuss the mechanisms underlying the development of motor complications, explain the technology and basic principles behind each of the three advanced treatments, present some evidence for and against each therapy, discuss how we should identify patients who might benefit from them, and conclude with advice on the selection of the right therapy for the right patient at the right time.
Abstract and Introduction
Abstract
Levodopa-induced motor complications of Parkinson's disease, including motor fluctuations and dyskinesias, become increasingly frequent as the disease progresses, and are often disabling. Oral and transdermal therapies have limited efficacy in controlling these problems. Advanced device-aided therapies, including continuous infusion of apomorphine, deep brain stimulation and levodopa-carbidopa intestinal gel can all ameliorate these complications. This review summarises the principles of each of these therapies, their modes of action, efficacy and adverse effects, and gives advice on timely identification of suitable patients and how to decide on the most appropriate therapy for a given patient.
Introduction
When appointed as a consultant neurologist in 2004, I set up a movement disorder clinic. Things seemed easy at first—I confidently diagnosed new patients with Parkinson's disease and started them on what I thought was the right treatment. Most responded and both they and I were pleased.
Eight years on, things are a bit different. I have learnt great respect for the principle that no two patients with Parkinson's disease are the same. Indeed, a few patients I diagnosed with Parkinson's turned out not to have it, a few others who did have Parkinson's have died, a few more have become demented and are in care homes, and still more have developed motor complications of levodopa therapy. Some of the motor complications are severe and have become resistant to medication tinkering. Some have gone on to receive one of the three main so-called 'advanced therapies':
apomorphine continuous subcutaneous infusion
functional neurosurgery/deep brain stimulation
continuous intrajejunal infusion of levodopa/carbidopa intestinal gel.
Some patients have done well, others less so. Did I make the right choices? I am interested in how to select patients for these. All are expensive, and not all are suitable for all advanced patients, and each can have serious complications. However, when you get it right, they can be life changing.
Geriatricians manage more patients with Parkinson's disease than neurologists in the UK, and there are wide variations in access to and experience of each treatment. Identifying patients who may benefit may be more difficult for a general neurologist in a busy general clinic than for a movement disorder neurologist in a tertiary specialist clinic. Some patients are referred much too late and others never get the opportunity. Therefore, my main aim is to help the generalist identify suitable patients for timely referral.
I will discuss the mechanisms underlying the development of motor complications, explain the technology and basic principles behind each of the three advanced treatments, present some evidence for and against each therapy, discuss how we should identify patients who might benefit from them, and conclude with advice on the selection of the right therapy for the right patient at the right time.
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