parkinson disease consensus
TRANSCRIPT
-
7/23/2019 Parkinson Disease Consensus
1/40
2012Consensus Guidelines
for the Treatment of
Parkinsons Disease
-
7/23/2019 Parkinson Disease Consensus
2/40
-
7/23/2019 Parkinson Disease Consensus
3/40
Authors note
Prof. Dr. LIM Shen-Yang
-
7/23/2019 Parkinson Disease Consensus
4/40
From the Movement Disorders Council, Malaysian Society of Neurosciences
Project Leader/Lead author:
Prof. Dr. Lim Shen-Yang MBBS (Melbourne), MD (Melbourne), FRACP (Aust), Fellowships in Movement Disorders (Melbourne & Toronto)
Co-authors:
Prof. Datin Dr. Norlinah Mohd. IbrahimMBBCH, BAO, BMedSci, MRCP, Fellowship in Movement Disorders (London)
Dr. Santhi Datuk Puvanarajah MBBS (Madras), MRCP (UK), AM (Malaysia)
Dr. Lee Moon KeenMBBS (Malaya), Dip Clin Neurology (London), FRCP (Edinburgh), FAM (Malaysia)
Dr. Chee Kok YoonMD (USM), MMed(Psych) (Malaysia), Fellowship in Neuropsychiatry (Melbourne)
Dr. Shanthi ViswanathanMBBS (India), MRCP (Ireland), Fellowship in Neurology (Malaysia)
Dr. Tan Ai HueyMD (UKM), MRCP (UK)
Dr. Chris Chong Kang Tird
MD (UKM), MRCP (UK), Fellowship in Movement Disorders (Monash)
Assoc. Prof. Dr. Kamal Azrin Bin Abdullah @ Kalai Arasu A/L MuthusamyMBBS (Malaya), MSurg (Malaya), DPhil (Oxon)
External Reviewers:
Prof. Emeritus Dr. Niall Quinn MA, MD (Cantab), FRCP (UK), FAAN
Assoc. Prof. Dr. Susan H. Fox BSc, MBChB, MRCP (UK), PhD
Acknowledgments:
Ms. Loh Hui Pin
Mr. Yap Kian Yong Mr. Calvin Kuan
-
7/23/2019 Parkinson Disease Consensus
5/40
degenerativedisease
older
motor
asymmetric
Non-motor symptoms
dopamine
1
1. Introduction - What is Parkinsons disease (PD)?
-
7/23/2019 Parkinson Disease Consensus
6/40
Contents
Appendices
1
3
15
6
20
31
13
18
29
24
-
7/23/2019 Parkinson Disease Consensus
7/40
Diagnosing Parkinsons disease.
9
Table 1.
2. Diagnosis of Parkinsons disease
3
Disorder Characteristic features
-
7/23/2019 Parkinson Disease Consensus
8/40
sporadic
no test
no cure worsens gradually well controlled
restoring dopaminergic
tailored
2
-
7/23/2019 Parkinson Disease Consensus
9/40
BrainMRI
Staging the severity of PD. Hoehn and Yahr (H&Y) stage
medication status
Table 2.
5
Hoehn & Yahr stage Description
1
2
3
4
5
; ;
;
-
7/23/2019 Parkinson Disease Consensus
10/404
Disorder Characteristic features
3
5
78
9
V
3
-
As a general rule, patients presenting with movementdisorders below age 50 should undergo tests to rule out this condition. 9 ;
>
A
-
7/23/2019 Parkinson Disease Consensus
11/40
Figure 1.
7
-
7/23/2019 Parkinson Disease Consensus
12/40
General approach.
symptomatic troublesome
as soon as, or very soon after, diagnosis patients preferences
start low, go slow
3. Initiation of antiparkinsonian medication -When and what to start
6
-
7/23/2019 Parkinson Disease Consensus
13/40
should not be inappropriately delayed
misconception saved for later
non-dopaminergic
Dopamine agonists.
9
-
7/23/2019 Parkinson Disease Consensus
14/40
Levodopa (L-dopa). the most effective 33
started at 50 mg daily every 3-7 days
Individual doses 50-300 mg 8
dyskinesias younger 35
younger patients 9 lowest effective dose
8
-
7/23/2019 Parkinson Disease Consensus
15/4011
Anticholinergic agents. trihexyphenidyl benzhexol orphenadrine tremor
dystonia7
Experimental treatments. 7
Non-pharmacologic management. physiotherapy
occupational therapy speech therapy
-
7/23/2019 Parkinson Disease Consensus
16/4010
Selegiline (e.g., Jumex and Selegos).
mild antiparkinsonian putative neuroprotective rasagiline
Table 3.
Dopamine agonist Usual starting doseMaximum
recommended dose
5 3
5
5 5
375 5
-
7/23/2019 Parkinson Disease Consensus
17/4013
start low, go slow
Dopaminergic side effects. dopaminergic3 nausea postural hypotension sleepiness confusionhallucinations impulse control disorders Domperidone
MAO-B inhibitors.
serotonin syndrome
57
Anticholinergic medications.
Amantadine.
4. Potential side effects of antiparkinsonianmedications
-
7/23/2019 Parkinson Disease Consensus
18/4012
dietitian PD nurse specialists
7
alternative therapies acupuncture
The importance of exercise. regular exercise 53
Being informed & being involved. information 7 information booklets
http://www.mpda.org.my
support group 7 8
-
7/23/2019 Parkinson Disease Consensus
19/4015
Wearing-off ON
OFF motor fluctuations non-motor fluctuations unpredictable
5. Motor response complications (motor fluctuations& dyskinesia) - What are they?
Figure 2.
(Wearing-off)
Peak-dose dyskinesia A typical day
TimeMedicationstarts to work
PD
medication
PD
medication
PD
medication
Sympt
oms a
re
allev
iated
Symptomsb
egin
toreturn
(ON condition)
(OFF condition)
Symptoms
adequately
controlled
Sym
ptomsnot
adequately
co
ntrolled
-
7/23/2019 Parkinson Disease Consensus
20/40
-
7/23/2019 Parkinson Disease Consensus
21/4017
Patient diary.
Peak-dose dyskinesia Biphasic dyskinesia
;
Table 4.
-
7/23/2019 Parkinson Disease Consensus
22/4016
Dyskinesia. wriggling peak-dose
biphasic
Figure 3. involuntary movements
Figure A. Tremor (shakes).
Figure B. Dyskinesia (wriggling).
ON
Figure C. Dystonia (twisting). OFF
A.
B.
C.
-
7/23/2019 Parkinson Disease Consensus
23/40
Treatment of dyskinesia.
misconception overdosed
the exactsame dose
Amantadine (Pk-Merz).
Motor response complications that are refractory to adjustment of oralmedications.
19
-
7/23/2019 Parkinson Disease Consensus
24/40
Treatment of motor fluctuations. dose and/or frequency
addition dopamine
agonist entacapone
beneficial effects on night-time sleep
Controlled-release L-dopa erratically absorbed 7
gradually, especiallyin a patient who is at higher risk of side effects
18
6. Treatment of motor fluctuations & dyskinesia
-
7/23/2019 Parkinson Disease Consensus
25/40
Other DBS targets. 78
Lesional (ablative) surgery. 7
Apomorphine (APO-go) (subcutaneous infusion or injections).
Jejunal L-dopa (Duodopa).
21
-
7/23/2019 Parkinson Disease Consensus
26/40
-
7/23/2019 Parkinson Disease Consensus
27/4023
Percutaneous endoscopicgastrostomy (PEG)
Infusion pump
CassettecontainingDuodopa
Intestinal tubing
Figure 6.
-
7/23/2019 Parkinson Disease Consensus
28/4022
Wire tunneledunder the skin
Tiny electrodes stimulate a deeppart of the brain (subthalamicnucleus / STN or globuspallidus internus / GPi)
Battery
Cloth pouch containingapomorphine reservoir& small infusion pump
Apomorphine delivered via veryfine plastic tubing, & butteryneedle sited under the skin
Figure 4.
Figure 5.
-
7/23/2019 Parkinson Disease Consensus
29/40
Figure 7.
25
Intrinsic toPD
Medicationeffect
Modifying factors(gender, genetic,
etc.)
V
Disease progression & Age
A A
Evolution of NMS
-
7/23/2019 Parkinson Disease Consensus
30/40
largenegative impact specifically asked about;
24
8. The non-motor symptoms of Parkinsons disease
-
7/23/2019 Parkinson Disease Consensus
31/40
-
7/23/2019 Parkinson Disease Consensus
32/4026
Non-motor symptoms Treatment Options Comments
Depression
3
53
5 Z 5
V 55 55 5 3 55 375875 X75375
5
;
;
A
8 ;
-
7/23/2019 Parkinson Disease Consensus
33/4029
Appendix 1: Parkinsons Disease DrugIdentication Chart
Comtan 200mg tabEntacapone
Madopar 100/25mg cap
Madopar 200/50mg tab
Madopar HBS 100/25mg cap
Levodopa/Benserazide
Bromocriptine
Stalevo 50(50/12.5/200mg)tab
Stalevo 100(100/25/200mg)tab
Stalevo 150(150/37.5/200mg)tab
Stalevo 200(200/50/200mg)tab
Levodopa/Carbidopa/Entacapone
Parlodel 2.5mg tab
Sinemet 25/100mg tab
Sinemet 25/250mg tab
Sinemet CR 50/200mg tab
Levodopa/Carbidopa
Levodopa-Based Medications
Direct Dopamine Agonists (Ergot)
-
7/23/2019 Parkinson Disease Consensus
34/4028
Non-motor symptoms Treatment Options Comments
Orthostatic hypotension (OH)
3
3
5 AA 5
3
A
X
8
3
3
5
A ; ;
3 A V5 3 A
V 5
Constipation
Urinary frequency andurgency, nocturia(overactive bladder)
Erectile dysfunction
Drooling
PD-related pain
A A 5 A 3
3 X
X
3 A
-
7/23/2019 Parkinson Disease Consensus
35/4031
Appendix 2 - Patient diary (for motor uctuationsand dyskinesia)
DAY ONE DATE:
Time
ONwithoutdyskinesia
ON withminordyskinesia
ON withtroublesomedyskinesia
OFF Asleep L-dopa intake(please stateexact time)
-
7/23/2019 Parkinson Disease Consensus
36/4030
Trihexyphenidylhydrochloride
Norex 100mg tab
Benzhexol 2mg tab
Direct Dopamine Agonists (Non-Ergot)
Others
Piribedil
Sifrol 1mg tab
Pramipexole
Pramipexole extendedrelease
Trivastal Retard 50mg SR tab
Sifrol 0.125mg tab
Ropinirole
Ropinirole prolongedrelease
Rotigotine transdermalpatch
Requip 0.25mg tab
Requip 1mg tab
Requip 2mg tab
Requip PD 2mg tab
Requip PD 4mg tab
Neupro
Sifrol ER 0.375mg tab
Sifrol ER 1.5 mg tab
Selegiline
Jumex 5mg tab
Selegos 5mg tab
Orphenadrine
Amantadine PK-Merz 100mg tab
2mg 4mg 6mg 8mg
-
7/23/2019 Parkinson Disease Consensus
37/40
-
7/23/2019 Parkinson Disease Consensus
38/40
References 1. 2.
3.
4. 5. 6.
7.
8. 9.
10. 11. 12. 13. 14. 15. 16. 17. 18.
19. 20.
21. 22. 23.
24. 25. 26.
27. 28.
-
7/23/2019 Parkinson Disease Consensus
39/40
-
7/23/2019 Parkinson Disease Consensus
40/40
54. 55. 56. 57.
58. 59. 60. 61.
62. 63.
64.
65.
66. 67.
68.
69. 70.
71. 72.
73.
74. 75. 76.