How to Use the New European Academy of Neurology/Movement Disorder Society European Section Guideline for Invasive Therapies in Parkinson's Disease

Abstract

Background: The decision to choose invasive treatments for Parkinson's disease (PD) is complex and needs careful consideration.

Objectives: Although the recommendations of the European Academy of Neurology/Movement Disorder Society European Section guideline for invasive therapies of PD are useful, the different clinical profiles of people with PD who seek advice for possible invasive therapy need further attention.

Methods and results: Here we describe 8 clinical standard situations of people with PD unsatisfied with their current oral treatment where invasive therapies may be considered. These are PD patients presenting with the following symptoms: (1) severe motor fluctuations, (2) beginning of levodopa-responsive fluctuations, severe tremor at (3) young or (4) advanced age, (5) impulse control disorders and related behavioral disorders, (6) hallucinations and psychosis, (7) minimal cognitive impairment or mild dementia, and (8) patients in need of palliative care. For some of these conditions, evidence at lower level or simple clinical considerations exist.

Conclusions: There are no one-fits-all answers, but physician and patient should discuss each option carefully considering symptom profile, psychosocial context, availability of therapy alternatives, and many other factors. The current paper outlines our proposed approach to these circumstances.

Keywords: Parkinson's disease; clinical pathway; infusion therapies; surgical interventions.

FIG. 1

Effect of the different interventions displayed as the difference in mean change (±95% confidence interval) between the interventional group and its study‐related control group for each of the interventions with control groups (original data, see Appendix 4 of the new guideline). Clinical head‐to‐head studies comparing the interventions are not available. In the case of severe adverse events the risk ratio and in the case of daily dose of levodopa (l‐dopa) equivalent the mean reduction (in mg) between the interventional and control groups are shown (Apo, apomorphine pump; DBS, deep‐brain stimulation; EarlyStim, deep‐brain stimulation in patients with PD with beginning fluctuations; FUS, focused ultrasound; LCIG, levodopa‐carbidopa intestinal gel; STN, subthalamic nucleus) cumulated from the RCTs (randomized controlled trial). The dot size indicates the number of subjects included in the trials. UPDRS (Unified Parkinson's Disease Rating Scale) II evaluates the motor aspects of experiencing daily living, UPDRS III rates the motor assessment in medication off (except for Apo and LCIG), and UPDRS IV evaluates the motor complications. Life quality estimated using the Parkinson's disease Quality of life Scale‐39 (PDQ‐39) except for Apo where the PDQ‐8 summary index was used. On‐time was defined as on‐time without troublesome dyskinesia (hours per day). Serious adverse events are defined as events that indicate further interventions or hospitalization. Daily dose of l‐dopa equivalent was calculated in each publication based on accepted conversion methods showing the daily intake of antiparkinsonian medication.