Clinical Scenario

This protocol applies to patients with Parkinson's disease who experience persistent levodopa-dependent motor fluctuations even after oral and transdermal treatment has been fully optimised. When conventional medication adjustments are no longer sufficient, a structured escalation pathway determines the appropriate next intervention.

Therapeutic Approach — Partial Overview

The protocol focuses on invasive and non-oral treatment strategies. Options span device-aided continuous infusion approaches and a surgical procedure, with one surgical modality specifically preferred over another based on the evidence. Patient-specific eligibility criteria, contraindications, and the decision sequence determine which option is appropriate — these details are available in the full regimen.

References

Invasive procedures should be considered when levodopa-dependent motor fluctuations persist despite optimizing oral/transdermal therapy.
Four pump therapies (Continuous subcutaneous Apomorphine infusion (CSAI), Levodopa-Carbidopa Intestinal Gel (LCIG), Levodopa/Entacapone/Carbidopa intestinal Gel (LECIG) and Foslevodopa/Foscarbidopa-Infusion (CSFLI)) have been approved for the treatment of motor fluctuations that cannot be adequately treated conservatively.
Subthalamic nucleus (STN) Deep Brain Stimulation (DBS) should be offered to patients with PD with motor fluctuations with and without dyskinesia that cannot be adequately treated with oral medication and at least 33% improvement in PD motor symptoms using a standardized levodopa test, taking into account the contraindications such as cognitive decline and severe psychiatric symptoms or other severe comorbidities.
STN DBS should be preferred over Globus Pallidus internus (GPi) DBS for PD patients with motor fluctuations (with and without dyskinesias).

DOI: 10.1186/s42466-024-00325-4

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Treatment of Parkinson's Disease When Motor Fluctuations Persist Despite Oral Therapy

Clinical Scenario

Therapeutic Approach — Partial Overview

References