disease - how it looks like from the doctor's
point of view
dr. Gilad Yahalom
The Movement Disortders insitue
Sheba - Medical Center
part 2
When agonnist are not effective enough, the doctor should consider starting levodopa, the most effective agent in the treatment of PD. Levodopa is a precursor of dopamine. One strives for the minimal does that enable a life with adequate quality. This interrellayion between the wish of the doctors to alleviato symptoms as much as possible but to give the patient this treatment as long as possible with minimal side effects is crucial and very hard to manage.The side effects mentioned earlier (motor fluctuation and dyskinesias), depend on the dose (high dose will shorten the time from the start of treatment until the onset of motor fluctuations).
In case of an elderly patient who is diagnosed with PD, the approach will be much less conservative and the initiation of treatment with levodopa is a good option as a first line treatment, since this is less related to side effects of effects of memory decline, confusion and hallucination than agonists or anticholinergic agents. However, even levodopa can inpair cognition and cause hallucination and confusion and sometimes the doctor is required to start anther medication to treat levodopa induced side effects of hallucinations and confusion (such as quetiapin or clozapin).
When standard medical therapy is no longer effective, other treatment option are now available, giving the patient a few more years of independence and adequate of life. to date, there are three possible options for advance treatment: treatment with coninuous opomorphine pump, treatment with continuos intestinal levodopa/carbidopa gel infusion - Duodopa, and treatment with deep brain stimulation.
Apomorphine is a highly potent dopaminergic agent administrated by subcutaneous injection. Its advantage is the quick response: patient can change from severe OFF state to ON within 5 - 10 minutes. However, its effect is relatively short duration, around 40 - 60 minutes. In recent years, an apomortphine pump was developed and it is now available as a continuous administration, thereby decreasing motor fluctuations (shortening the OFF state and prolonging the ON state), with a marked improvement in quality of life in many patient.
On the same principle Duotopa was developed. Duodopa is a gel conaining levodopa and is a administrated by means of protable, patient controlled Duodopa pump, directly to the deudenum through a permanet catheter implanted via percutaneous endoscopie gastrojejunostomy (PEG). The principle behind Duodopa theropy is stabilizing levodopa plasma levels by bypassing the stomach and transferring a continuous infusion of levodopa directly to the area of absorption in the small intesine. The downside here is that it requires the procedure to install the PEG and some patients refraim from the procedure for cosmetic reasons. Such patients often prefer the use of opomorphine pump which is a reversible device, without the need to undergo the procedure of PEG insertion.
Deep brain stimulation is an effective treatment that provides in some case many years of quality of life once the standard oral therapy is no longer effective. However there are several problams: it is head operation which requires the insertion of electrodes deep into the brain, with all the associated possible complications of such an operation.
There are several possible sites where the electrodes could be implanted. The location of the electrode is selected according to clinical judgment. After transplantation, speech or behavioral disturbances (cognitive impairment, depression etc.) may appear or become worse. These side effects could be stimulation-induced or independent to the strength of stimulation. Therefore, each individual candidate for deep brain stimulation should be strictly evaluated by a psychologist, social worker, and a psychiatrist to screen for patients at risk.
Complications of pacemaker implantation correlate with the age of patient. The approach to treat the elderly is much more conservative. The practical cut-off age after wich on operation is discouraged is around the age of 70 years, but each case should be considered individually.
In conclusion, the diagnosis of PD is offen perceived by the patient as a shock. Some patients become depressed simply after hearing the diagnosis, and understanding that they suffer from a chronic disease for the rest of their life. However, and unlike most neurodegenerative disorders (such as Alzheimer's disease or other parkinsoniam disorders). PD has effective treatment thay alleviates symptoms and enables the patient to live independently in considerable quality of life for many years.
To date, there is a great interest to develop a neuroprotective therapy, which will modify the course of the disease (thus, slowing down or arresting progression). Currently, the best disease modifying treatment in exercise which was proved to slow down progression. There is now growing awareness that physical activity improves function such as walking, postural stability and nonmotor complaints (such as pain, fatigue, mood), along with its neuroprotective effect. Hence, physical activity has become in recent years and integral part in the management of PD.
Apomorphine is a highly potent dopaminergic agent administrated by subcutaneous injection. Its advantage is the quick response: patient can change from severe OFF state to ON within 5 - 10 minutes. However, its effect is relatively short duration, around 40 - 60 minutes. In recent years, an apomortphine pump was developed and it is now available as a continuous administration, thereby decreasing motor fluctuations (shortening the OFF state and prolonging the ON state), with a marked improvement in quality of life in many patient.
On the same principle Duotopa was developed. Duodopa is a gel conaining levodopa and is a administrated by means of protable, patient controlled Duodopa pump, directly to the deudenum through a permanet catheter implanted via percutaneous endoscopie gastrojejunostomy (PEG). The principle behind Duodopa theropy is stabilizing levodopa plasma levels by bypassing the stomach and transferring a continuous infusion of levodopa directly to the area of absorption in the small intesine. The downside here is that it requires the procedure to install the PEG and some patients refraim from the procedure for cosmetic reasons. Such patients often prefer the use of opomorphine pump which is a reversible device, without the need to undergo the procedure of PEG insertion.
Deep brain stimulation is an effective treatment that provides in some case many years of quality of life once the standard oral therapy is no longer effective. However there are several problams: it is head operation which requires the insertion of electrodes deep into the brain, with all the associated possible complications of such an operation.
There are several possible sites where the electrodes could be implanted. The location of the electrode is selected according to clinical judgment. After transplantation, speech or behavioral disturbances (cognitive impairment, depression etc.) may appear or become worse. These side effects could be stimulation-induced or independent to the strength of stimulation. Therefore, each individual candidate for deep brain stimulation should be strictly evaluated by a psychologist, social worker, and a psychiatrist to screen for patients at risk.
Complications of pacemaker implantation correlate with the age of patient. The approach to treat the elderly is much more conservative. The practical cut-off age after wich on operation is discouraged is around the age of 70 years, but each case should be considered individually.
In conclusion, the diagnosis of PD is offen perceived by the patient as a shock. Some patients become depressed simply after hearing the diagnosis, and understanding that they suffer from a chronic disease for the rest of their life. However, and unlike most neurodegenerative disorders (such as Alzheimer's disease or other parkinsoniam disorders). PD has effective treatment thay alleviates symptoms and enables the patient to live independently in considerable quality of life for many years.
To date, there is a great interest to develop a neuroprotective therapy, which will modify the course of the disease (thus, slowing down or arresting progression). Currently, the best disease modifying treatment in exercise which was proved to slow down progression. There is now growing awareness that physical activity improves function such as walking, postural stability and nonmotor complaints (such as pain, fatigue, mood), along with its neuroprotective effect. Hence, physical activity has become in recent years and integral part in the management of PD.
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