Parkinson Disease Consensus

7/23/2019 Parkinson Disease Consensus

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2012Consensus Guidelines

for the Treatment of

Parkinsons Disease


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Authors note

Prof. Dr. LIM Shen-Yang


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From the Movement Disorders Council, Malaysian Society of Neurosciences

Project Leader/Lead author:

Prof. Dr. Lim Shen-Yang MBBS (Melbourne), MD (Melbourne), FRACP (Aust), Fellowships in Movement Disorders (Melbourne & Toronto)

Co-authors:

Prof. Datin Dr. Norlinah Mohd. IbrahimMBBCH, BAO, BMedSci, MRCP, Fellowship in Movement Disorders (London)

Dr. Santhi Datuk Puvanarajah MBBS (Madras), MRCP (UK), AM (Malaysia)

Dr. Lee Moon KeenMBBS (Malaya), Dip Clin Neurology (London), FRCP (Edinburgh), FAM (Malaysia)

Dr. Chee Kok YoonMD (USM), MMed(Psych) (Malaysia), Fellowship in Neuropsychiatry (Melbourne)

Dr. Shanthi ViswanathanMBBS (India), MRCP (Ireland), Fellowship in Neurology (Malaysia)

Dr. Tan Ai HueyMD (UKM), MRCP (UK)

Dr. Chris Chong Kang Tird

MD (UKM), MRCP (UK), Fellowship in Movement Disorders (Monash)

Assoc. Prof. Dr. Kamal Azrin Bin Abdullah @ Kalai Arasu A/L MuthusamyMBBS (Malaya), MSurg (Malaya), DPhil (Oxon)

External Reviewers:

Prof. Emeritus Dr. Niall Quinn MA, MD (Cantab), FRCP (UK), FAAN

Assoc. Prof. Dr. Susan H. Fox BSc, MBChB, MRCP (UK), PhD

Acknowledgments:

Ms. Loh Hui Pin

Mr. Yap Kian Yong Mr. Calvin Kuan


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degenerativedisease

older

motor

asymmetric

Non-motor symptoms

dopamine

1

1. Introduction - What is Parkinsons disease (PD)?


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Contents

Appendices

1

3

15

6

20

31

13

18

29

24


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Diagnosing Parkinsons disease.

9

Table 1.

2. Diagnosis of Parkinsons disease

3

Disorder Characteristic features


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sporadic

no test

no cure worsens gradually well controlled

restoring dopaminergic

tailored

2


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BrainMRI

Staging the severity of PD. Hoehn and Yahr (H&Y) stage

medication status

Table 2.

5

Hoehn & Yahr stage Description

1

2

3

4

5

; ;

;


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Disorder Characteristic features

3

5

78

9

V

3

-

As a general rule, patients presenting with movementdisorders below age 50 should undergo tests to rule out this condition. 9 ;

>

A


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Figure 1.

7


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General approach.

symptomatic troublesome

as soon as, or very soon after, diagnosis patients preferences

start low, go slow

3. Initiation of antiparkinsonian medication -When and what to start

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should not be inappropriately delayed

misconception saved for later

non-dopaminergic

Dopamine agonists.

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Levodopa (L-dopa). the most effective 33

started at 50 mg daily every 3-7 days

Individual doses 50-300 mg 8

dyskinesias younger 35

younger patients 9 lowest effective dose

8


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Anticholinergic agents. trihexyphenidyl benzhexol orphenadrine tremor

dystonia7

Experimental treatments. 7

Non-pharmacologic management. physiotherapy

occupational therapy speech therapy


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Selegiline (e.g., Jumex and Selegos).

mild antiparkinsonian putative neuroprotective rasagiline

Table 3.

Dopamine agonist Usual starting doseMaximum

recommended dose

5 3

5

5 5

375 5


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start low, go slow

Dopaminergic side effects. dopaminergic3 nausea postural hypotension sleepiness confusionhallucinations impulse control disorders Domperidone

MAO-B inhibitors.

serotonin syndrome

57

Anticholinergic medications.

Amantadine.

4. Potential side effects of antiparkinsonianmedications


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dietitian PD nurse specialists

7

alternative therapies acupuncture

The importance of exercise. regular exercise 53

Being informed & being involved. information 7 information booklets

http://www.mpda.org.my

support group 7 8


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Wearing-off ON

OFF motor fluctuations non-motor fluctuations unpredictable

5. Motor response complications (motor fluctuations& dyskinesia) - What are they?

Figure 2.

(Wearing-off)

Peak-dose dyskinesia A typical day

TimeMedicationstarts to work

PD

medication

PD

medication

PD

medication

Sympt

oms a

re

allev

iated

Symptomsb

egin

toreturn

(ON condition)

(OFF condition)

Symptoms

adequately

controlled

Sym

ptomsnot

adequately

co

ntrolled


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Patient diary.

Peak-dose dyskinesia Biphasic dyskinesia

;

Table 4.


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Dyskinesia. wriggling peak-dose

biphasic

Figure 3. involuntary movements

Figure A. Tremor (shakes).

Figure B. Dyskinesia (wriggling).

ON

Figure C. Dystonia (twisting). OFF

A.

B.

C.


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Treatment of dyskinesia.

misconception overdosed

the exactsame dose

Amantadine (Pk-Merz).

Motor response complications that are refractory to adjustment of oralmedications.

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Treatment of motor fluctuations. dose and/or frequency

addition dopamine

agonist entacapone

beneficial effects on night-time sleep

Controlled-release L-dopa erratically absorbed 7

gradually, especiallyin a patient who is at higher risk of side effects

18

6. Treatment of motor fluctuations & dyskinesia


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Other DBS targets. 78

Lesional (ablative) surgery. 7

Apomorphine (APO-go) (subcutaneous infusion or injections).

Jejunal L-dopa (Duodopa).

21


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Percutaneous endoscopicgastrostomy (PEG)

Infusion pump

CassettecontainingDuodopa

Intestinal tubing

Figure 6.


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Wire tunneledunder the skin

Tiny electrodes stimulate a deeppart of the brain (subthalamicnucleus / STN or globuspallidus internus / GPi)

Battery

Cloth pouch containingapomorphine reservoir& small infusion pump

Apomorphine delivered via veryfine plastic tubing, & butteryneedle sited under the skin

Figure 4.

Figure 5.


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Figure 7.

25

Intrinsic toPD

Medicationeffect

Modifying factors(gender, genetic,

etc.)

V

Disease progression & Age

A A

Evolution of NMS


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largenegative impact specifically asked about;

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8. The non-motor symptoms of Parkinsons disease


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Non-motor symptoms Treatment Options Comments

Depression

3

53

5 Z 5

V 55 55 5 3 55 375875 X75375

5

;

;

A

8 ;


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Appendix 1: Parkinsons Disease DrugIdentication Chart

Comtan 200mg tabEntacapone

Madopar 100/25mg cap

Madopar 200/50mg tab

Madopar HBS 100/25mg cap

Levodopa/Benserazide

Bromocriptine

Stalevo 50(50/12.5/200mg)tab

Stalevo 100(100/25/200mg)tab

Stalevo 150(150/37.5/200mg)tab

Stalevo 200(200/50/200mg)tab

Levodopa/Carbidopa/Entacapone

Parlodel 2.5mg tab

Sinemet 25/100mg tab

Sinemet 25/250mg tab

Sinemet CR 50/200mg tab

Levodopa/Carbidopa

Levodopa-Based Medications

Direct Dopamine Agonists (Ergot)


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Non-motor symptoms Treatment Options Comments

Orthostatic hypotension (OH)

3

3

5 AA 5

3

A

X

8

3

3

5

A ; ;

3 A V5 3 A

V 5

Constipation

Urinary frequency andurgency, nocturia(overactive bladder)

Erectile dysfunction

Drooling

PD-related pain

A A 5 A 3

3 X

X

3 A


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Appendix 2 - Patient diary (for motor uctuationsand dyskinesia)

DAY ONE DATE:

Time

ONwithoutdyskinesia

ON withminordyskinesia

ON withtroublesomedyskinesia

OFF Asleep L-dopa intake(please stateexact time)


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Trihexyphenidylhydrochloride

Norex 100mg tab

Benzhexol 2mg tab

Direct Dopamine Agonists (Non-Ergot)

Others

Piribedil

Sifrol 1mg tab

Pramipexole

Pramipexole extendedrelease

Trivastal Retard 50mg SR tab

Sifrol 0.125mg tab

Ropinirole

Ropinirole prolongedrelease

Rotigotine transdermalpatch

Requip 0.25mg tab

Requip 1mg tab

Requip 2mg tab

Requip PD 2mg tab

Requip PD 4mg tab

Neupro

Sifrol ER 0.375mg tab

Sifrol ER 1.5 mg tab

Selegiline

Jumex 5mg tab

Selegos 5mg tab

Orphenadrine

Amantadine PK-Merz 100mg tab

2mg 4mg 6mg 8mg


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References 1. 2.

3.

4. 5. 6.

7.

8. 9.

10. 11. 12. 13. 14. 15. 16. 17. 18.

19. 20.

21. 22. 23.

24. 25. 26.

27. 28.


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54. 55. 56. 57.

58. 59. 60. 61.

62. 63.

64.

65.

66. 67.

68.

69. 70.

71. 72.

73.

74. 75. 76.

Documents

Parkinson Disease Consensus