OPTIMAL TIMING FOR THE TREATMENT OF ADVANCED MOTOR- AND NON- MOTOR SYMPTOMS IN PARKINSONS'S DISEASE; THE PROS OF AN EARLY START OF ADVANCED THERAPIES Teus Van Laar
Department of Neurology, Movement Disorder Unit, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
The start of the advanced stage of PD is still under debate in the literature, which may lead to a delayed introduction of the so-called advanced stage therapies, like deep brain stimulation (DBS), subcutaneous apomorphine infusion (APO-go) and jejunal infusion with levodopa/carbidopa gel (Duodopa).
In this lecture argument to define the advanced stage by the occurrence of unpredictable on-off fluctuations and/or severe hyperkinesia, not responsive to oral treatment, will be discussed. Most patients will show these advanced stage symptoms within 10 yrs. after being diagnosed as PD. However, less than 5% of the advanced PD patients are treated with apomorphine, Duodopa or DBS, which means a severe undertreatment of this patient group. This lecture will discuss the pros of an earlier start of these advanced stage therapies.
The timing of these therapies is crucial, because of the progressive narrowing of the therapeutic window during the course of the disease. If apomorphine, Duodopa and DBS are started too late in the course of PD, the clinical results will be much worse as compared to earlier use. Clinical data will be shown to support this hypothesis, f.i. the data of the EARLY STIM trial.
The advanced stage therapies are also suitable to treat non-motor symptoms, like sleeping problems, mood disturbances and even visual hallucinations in the case of apomorphine. Also the treatment of these non-motor symptoms may be improved by introducing advanced stage therapies at an earlier phase of the disease.
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2. Continuous subcutaneous infusion of apomorphine can be used safely in patients with Parkinson's disease and pre-existing visual hallucinations. van Laar T, Postma AG, Drent M. Parkinsonism Relat Disord. 2010;16(1):71-2.
3. Stimulation of the subthalamic nucleus at an earlier disease stage of Parkinson's disease: Concept and standards of the - . Deuschl G, Schüpbach M, Knudsen K, Pinsker MO, Cornu P, Rau J, Agid Y, Schade-Brittinger C.
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