Where is the evidence on treatments for Parkinson's disease motor fluctuations? How do we choose? Remember – ense et aratro – sometimes we choose the sword, but in Parkinson's, over time the plow is usually the better strategy. de Bie and colleagues do an evidence-based review in the journal Movement Disorders.
Key Points:
-What is a motor fluctuation?
- Here is a greatest hits list (7): 1- alternating periods of good movement control referred to as on, and poor movement control referred to as off. 2- wearing-off, 3- sudden shifts between on and off, 4- delayed onset of doses working, 5- dose failure, 6- freezing, and 7-dyskinesia.
- The International Parkinson and Movement Disorder Society (MDS) Evidence Based Medicine in Movement Disorders Committee updated recommendations based on all available research studies.
- 102 studies met criteria.
- Efficacious: levodopa extended release, pramipexole immediate release and extended release, ropinirole immediate release, rotigotine, opicapone, safinamide, and bilateral subthalamic nucleus deep brain stimulation (DBS).
- Likely efficacious: continuous intestinal levodopa infusion, continuous subcutaneous levodopa, continuous subcutaneous apomorphine, ropinirole prolonged release, ropinirole patch, entacapone, rasagiline, istradefylline, amantadine extended release, zonisamide, bilateral globus pallidus DBS, and pallidotomy.
My take: Parkinson's, in my opinion, is the most complex disease in clinical medicine. Though it is nice to see these evidence-based reviews, we should keep our eye on the 'ball.' The ball is dynamic, and in Parkinson's will fluctuate over time, and especially with disease progression. We need to listen carefully to the persons with disease. We need to pay attention to the timing of dosages and realize that more is not always better. We need to choose the 'cocktail of the day' for medications, and realize the mixture will change over time. We need to know when to pull the trigger for DBS, focused ultrasound or pumps, and also to not forget that exercise and multi-disciplinary therapies, as well as diet and sleep, can also help. Zonisamide is not used much in Western countries, and perhaps we should consider this choice more often? Remember, despite where the level of evidence is at the moment, we are pretty sure that GPi DBS is currently the best overall therapy for dyskinesia, and especially for brittle dyskinesia. Remember – ense et aratro – sometimes we choose the sword, but in Parkinson's over time the plow is the better strategy.
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