Transcript Document
Learning objectives At the end of this section you will: Have applied the knowledge gained from the earlier sessions to: • Understand the impact of pulsatile dopaminergic therapy-induced motor complications on patient functioning • Identify which patient types could benefit from the three CDS treatments currently available Case study 1 Patient history • Diagnosed 1986 • His life revolved around taking tablets • Problems with sleep, which had an impact on his quality of life • In 1999, he received carbidopa/levodopa infusion for the first time • A PEG operation was performed in May 2000 Discussion Q. What additional options are available to further improve the quality of life of this patient? Results • Since 2002, 24-hour infusion has improved his sleep • Few drawbacks • From having a life dominated by tablet-taking, increasingly severe motor functions and very poor sleep, patient feels that he can once again fill his time with meaningful activities • At the latest follow-up, he described his motor functions and sleep as good CDS impact on sleep 24-hour infusion – impact on sleep (N=1; PD sleep scale; maximum 150; HY stage 4-5:~90) Adapted from Nyholm et al. Neurology 2005;65: 1506-7 ‘On/off’ mobility chart On/Off mobility chart: conventional treatment versus intraduodenal carbidopa/levodopa gel infusion Intraduodenal carbidopa/levodopa gel infusion Anders. Data on file Conclusions • DBS not suitable due to previous depression • Without pump therapy living alone would not have been possible • Living alone is possible with intraduodenal carbidopa/levodopa gel infusion in some cases • 24-hour infusion of great benefit for this patient Case study 2 Patient history • Male, 58 years old • Occupation: teacher • Parkinson‘s disease since the age of 45, otherwise healthy • Motor fluctuations and dyskinesias since the age of 52 Patient history Symptoms and treatment 2005 • ‘On-off‘ fluctuations; severe ‘off’ phases with freezing; ‘on’ phases with pronounced dyskinesias • Depressive symptoms • No dementia • Medication: – Pramipexole 1.4 mg daily – Levodopa 525 mg daily – Entacapone 1400 mg daily – Amantadine 200 mg daily – Quetiapine 50 mg daily Patient history Symptoms and behaviour Dopamine dysregulation syndrome (DDS) • Went to several doctors for prescriptions • Consumed up to 3 g of levodopa daily • Did not follow advice to restrict medication at all • Punding Impulse control disorder (ICD) • Hypersexuality – Called sex hotlines – Visited prostitutes daily • Gambling – Lost large parts of personal savings Dopaminergic psychotic symptoms • Hallucinations • Confusion Patient history Consequences of actions • Lost family, home • Legal guardian necessary to control his economy • Nursing home Treatment Step 1 • Levodopa monotherapy 800 mg daily • Result: – Psychotic symptoms improved, but did not disappear – DDS and ICD did not change – Motor fluctuations and dyskinesias worsened Treatment Step 2 • Quetiapine raised to 200 mg daily • Result – DDS and ICD did not change Discussion Q. Considering the results from treatment step 2, which treatment option would be appropriate for the next treatment step: • DBS? • Subcutaneous apomorphine infusion? • Intraduodenal carbidopa/levodopa gel infusion? • Other? Treatment Step 3 Treatment: • Intraduodenal carbidopa/levodopa gel infusion 5.2 ml/h daytime, 3.6 ml/h night-time, bolus: 2 ml, max 5 per day • Quetiapine 75 mg daily • All other medication stopped Result: • DDS resolved almost completely • ICD resolved completely • No psychotic symptoms, no confusion • Cognitive functions normal • Strong improvement of motor fluctuations Side effects: • Percutaneous endoscopic jejunostomy (PEJ) problems x 2, replaced Discussion Q. In your opinion, what was the underlying reason for the improvements observed with intraduodenal carbidopa/levodopa gel infusion?