Movement Disorders, Parkinson's Disease
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Managing for the Long-term – Strategies for Initiating and Maintaining Successful Continuous Dopaminergic Stimulation Treatment

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Published Online: Jul 15th 2012 European Neurological Review, 2012;7(Suppl. 1):31–5 DOI:
Authors: Tove Henriksen, Per Odin, Jens Volkmann, Angelo Antonini
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There are many factors that may influence treatment choice in patients with Parkinson’s disease. While ‘inclusion’ criteria include the clinical need for short- and long-term improvement, there are some well defined contraindications to continuous dopaminergic stimulation (CDS) therapies, such as age, cognitive impairment, psychosis or severe orthostatic hypotension. These contraindications vary between CDS therapies and can help guide the choice of treatment. Patient preferences and the practicalities of the treatment modality also play an important part in the decision-making process. Treatment selection algorithms have been developed and presented, but they require refining and need to be expanded to include guidance on management decisions – for example, when initial CDS therapy fails. While more trial data are gathered and as management algorithms evolve, case studies continue to provide important information on practical aspects of CDS therapies.


Parkinson’s disease, continuous dopaminergic stimulation, deep brain stimulation, subcutaneous apomorphine infusion, levodopa/carbidopa intestinal gel infusion, treatment selection algorithm


Options for Continuous Dopaminergic Stimulation Therapy
In patients with advanced Parkinson’s disease (APD), worsening motor symptoms due to motor response complications and dyskinesia (exacerbated by erratic gastric emptying associated with peroral therapy) may be treated optimally by switching to continuous dopaminergic stimulation (CDS) therapy. There are three CDS therapy options widely available for the treatment of APD:

  • levodopa/carbidopa intestinal gel (LCIG) infusion;
  • subcutaneous apomorphine (APO) infusion; and
  • deep brain stimulation (DBS; primarily of the subthalamic nucleus [STN]), which is not strictly a CDS treatment but has similar effects.

But how do we choose between these treatments for a given Parkinson’s disease (PD) patient? Currently, there are no large-scale, randomised, placebo-controlled trials directly comparing the three CDS treatment options. We must therefore rely on indirect comparisons and a growing body of clinical experience to judge the appropriateness of each CDS therapy for individual patients.

Factors to Aid Treatment Choice
Inclusion and Exclusion Criteria
We can use various criteria to decide whether a patient is appropriate for a given treatment, including age, cost, practicalities (e.g., feasibility of surgery or availability of a multidisciplinary care team), cognitive impairment or psychosis (see Figure 1). APO infusion is the ‘simplest’ treatment in terms of administration, but may be slightly less effective in treating motor complications than DBS or LCIG infusion. Furthermore, different CDS treatments appear to improve different non-motor symptoms (NMS). If there is a 24-hour clinical need, DBS may be the better choice and, in the long-term, may be cheaper than pump therapies. If the patient is aged >70 years, they may not be a good candidate for DBS given the risks of surgery. In addition, cognitive impairment or severe psychosis may preclude all CDS therapies, but especially DBS. Patients with impulse control disorder, hypersexuality or severe orthostatic hypotension may not be good candidates for APO infusion. Co-morbidities such as gastrointestinal problems may make percutaneous endoscopic gastrostomy (PEG) fitting for LCIG infusion problematic. Any other disease that has an effect on life expectancy may make the neurologist more reluctant to suggest surgery, given the added risk of unpleasant side effects that may lead to death or severe morbidity.

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Article Information:

Tove Henriksen has a consultancy agreement with Medtronic and an advisory board agreement with Abbott. Per Odin has received honoraria for lectures and participation in advisory boards from Boehringer Ingelheim, Abbott, Cephalon, Union Chimique Belge (UCB) and GlaxoSmithKline (GSK). Jens Volkmann has no conflicts of interest to declare. Angelo Antonini has received honoraria for consulting services and symposia from Abbott, Boehringer Ingelheim, GSK, Lundbeck, UCB, Novartis and Merck-Serono.


Tove Henriksen, Movement Disorder Clinic, Bispebjerg Hospital, University Hospital of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark. E:


The V International Forum on Parkinson’s Disease (Helsinki, Finland, 6–7 May 2011) was funded by an unrestricted educational grant from Abbott. Abbott funded the development of this supplement by ESP Bioscience (Crowthorne, UK). Emily Chu and Nicole Meinel of ESP Bioscience provided medical writing and editorial support to the authors in the development of this publication. Abbott had the opportunity to review and comment on the publication’s content; however, all decisions regarding content were made by the authors. Tove Henriksen would like to thank Narissah Bryndum, Parkinson’s disease nurse at Bispebjerg Hospital.




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