Opinion
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Adjusting and Changing Treatment Regimens in Parkinson Disease
Panelists discuss how treatment changes in Parkinson disease are necessitated by disease progression, diminishing medication effectiveness, and emerging motor complications, examining a physician’s systematic approach to treatment adjustments and the range of available options for managing off fluctuations.
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Treatment Changes and Options for Off Fluctuations
Primary Reasons for Treatment Changes:
- Diminishing efficacy of current regimen
- Emergence/worsening of motor fluctuations and dyskinesias
- Development of adverse effects
- Disease progression affecting nonmotor symptoms
- Cognitive decline affecting medication adherence
Process for Treatment Adjustment:
- Assess pattern and timing of symptoms (symptom diaries)
- Optimize oral levodopa dosing (dose/frequency adjustments)
- Add adjunctive medications strategically
- Consider advanced therapies when oral medications are inadequate
- Regular follow-up to monitor response and adjust as needed
Current Options for Off Fluctuations:
- Levodopa optimization: dose adjustments, controlled-release formulations
- Adjunctive therapies: COMT inhibitors, MAO-B inhibitors, dopamine agonists
- Rescue therapies: apomorphine injection, levodopa inhalation powder, sublingual apomorphine
- Advanced therapies: deep brain stimulation, continuous infusion therapies (levodopa intestinal gel, subcutaneous apomorphine)
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