Case study 1Patient history

• Female retired farmer, born 1932

• 1988: pain right shoulder → physiotherapy, analgesics

• 1991: Parkinson‘s disease diagnosed, good levodopa response

• Around 1994: motor fluctuations

• Pergolide added, later → pramipexole

• 2005: osteoporotic vertebral fracture → uses sticks for walking

Patient historyTreatment

• Dyskinesias: choreatic, peak dose, socially embarrassing & physically disabling

• ↑ Entacapone; amantadine: no effect

• ‛Off’ time ~3 hours/day

• Marked non-motor ‛off‘ symptoms: shoulder / back pain, dysphoria, anxiety

• Medication:

– ASS 100 mg

– Alendronate 70 mg/wk

– Levodopa/benserazide 200/50 ½ - ½ - ½ - ¼ - ¼ - ¼ - 0

100/25 CR 1

– Pramipexole 0.7mg 1 – 0 – 1 – 1 – 0 – 0 – 0

– Oxycodone 10 mg ½ - 0 – 0 – 0 – 0 – 0 – ½

Discussion

Q. Which factors should be considered in the next

treatment decision for this patient?

Q. Given the factors considered above, which treatment

would you select?

ResultsBefore apomorphine

ResultsOn subcutaneous apomorphine infusion treatment

Initiated February 2006

• Apomorphine: Flow rate: 7 mg/h; 14 hours/day

• Morning: ½ levodopa/benserazide 200/50 + 1 soluble 100/25

• Bedtime: ½ levodopa/benserazide 200/50

• ¼ levodopa/benserazide 200/50 when required (~ 1/day)

• Domperidone 60 mg/day

• Oxycodone discontinued; non-motor ‘off’ problems much improved

May 2008

ResultsCurrent status

Permission kindly granted by Dr Regina Katzenschlager

ResultsCurrent status

Case study 2Patient history

• Social history: head of a department of transportation. Occasional work at night and odd hours. Active recreation activities; fishing, hunting, riding bicycle

• PD diagnosis at age 50

• After 1.5 years of L-dopa fluctuations, entacapone started with good effect, but diarrhoea (transient)  

• Levodopa/benserazide 125 1½ x 6, cabergoline 6 mg /day, entacapone 200 mg tid 

• 2006: mitral insufficiency cabergoline stopped, pramipexole 1.05 mg tid

• Levodopa/benserazide 125 x 7, levodopa/benserazide 62.5 x 4, soluble levodopa/benserazide 62.5 x 1, levodopa/benserazide SR 125 x 1; total L-dopa: 1.05 g / day

• Fluctuations, no ‘on’, dystonic pain, slight hyperkinesias

Discussion

Q. Which factors should be considered in the next

treatment decision for this patient?

Q. Given the factors considered above, which treatment

would you select?

Patient historyTreatment

• August 2007: Apomorphine pump 6.8 mg/h, reduction of oral medication

• August 2009: pump (7.25 mg/h) during waking hours. Fully active at work and with recreation activities. Uses pen if on call and called out in the night, and for dystonic leg cramps

ResultsCurrent status

• Sleeps through the night for the first time in years

• No ‘off’ periods during waking hours. Feels independent

• Medication:– Madopar 125 mg x 4, entacapone 200 mg x 4, Madopar SR 125 mg x 2;

– Total L-dopa reduction: 62 %

• Side effects:– Small skin nodules