Subcutaneous apomorphine infusion (Apo) and intrajejunal levodopa infusion (IJLI) are two treatment options for patients with advanced Parkinson's disease (PD) and refractory motor complications, with varying cost of treatment. There are no multicenter studies comparing the effects of the two strategies. This open-label, prospective, observational, 6-month, multicenter study compared 43 patients on Apo (48.8% males, age 62.3 ± 10.6 years; disease duration: 14 ± 4.4 years; median H & Y stage 3; interquartile range [IQR]: 3-4) and 44 on IJLI (56.8% males, age 62.7 ± 9.1 years; disease duration: 16.1 ± 6.7 years; median H & Y stage 4; IQR, 3-4). Cohen's effect sizes (≥0.8 considered as large) were "large" with both therapies with respect to total motor, nonmotor, and quality-of-life scores. The Non-Motor Symptoms Scale (NMSS) with Apo showed moderate improvement, whereas sleep/fatigue, gastrointestinal, urinary, and sexual dimensions of the NMSS showed significantly higher improvement with IJLI. Seventy-five percent on IJLI improved in their quality-of-life and nonmotor symptoms (NMS), whereas in the Apo group, a similar proportion improved in quality of life, but 40% in NMS. Adverse effects included peritonitis with IJLI and skin nodules on Apo. Based on this open-label, nonrandomized, comparative study, we report that, in advanced Parkinson's patients, both IJLI and Apo infusion therapy appear to provide a robust improvement in motor symptoms, motor complications, quality-of-life, and some NMS. Controlled, randomized studies are required.

Dopamine agonist withdrawal syndrome (DAWS) has been reported in patients with Parkinson's disease (PD) who rapidly decrease or stop their dopamine agonist (DA) treatment. Retrospective studies suggest a high prevalence of DAWS (14%-18%) in PD, but there are no prospective studies. We report data from the first pilot European multicenter prospective study addressing the frequency of probable DAWS (Rabinak-Nirenberg criteria) in PD patients. The self-completed Nonmotor Symptoms Questionnaire (which addresses the core features of DAWS) was administered at clinical follow-up at 1 month in 51 patients (33 male; mean age: 73.0 AE 9.9 years; PD duration: 12.2 AE 6.3 years) who had discontinued dopamine agonists. Twelve out of fifty-one patients (24%) met clinical criteria for DAWS, the most common symptoms of which were anxiety (91.7%), pain (50%), sweating (41.7%), and anhedonia (16.7%), after the withdrawal of a DA (ropinirole, pramipexole, or cabergoline). In this first prospective evaluation of DAWS in the clinic, preliminary data indicate a high rate after discontinuation of a range of DAs, particularly in the context of impulse control disorders. Larger, controlled studies are required to establish a definitive management pathway.Dopamine agonist withdrawal syndrome (DAWS) has emerged as a therapeutic challenge in Parkinson's disease (PD). The reported symptoms are stereotyped and consist of psychiatric, autonomic, and sensory symptoms, similar to those of addictive drug withdrawal. 1 The condition has been recently characterized and described in people with PD who decrease or stop their dopamine agonist (DA) treatment. 2,3 A prevalence of DAWS of 14% to 18% in PD patients who taper a DA has been reported in retrospective studies, with an even higher prevalence in those who taper a DA in the setting of baseline impulse control disorders. 1,2 At this time, we are not aware of any prospective studies addressing the frequency of this problem in the clinic. We report a prospective, multicenter, observational study that specifically addressed occurrence of DAWS in consecutive PD patients on DA treatment who underwent stoppage of DA treatment using the DAWS criteria defined by Rabinak and Nirenberg, supplemented by relevant questions on the Nonmotor Symptoms Questionnaire (NMSQuest). 4 Patients and MethodsFor a period of 6 months (November 2012-May 2013, all PD patients whose DA treatment was tapered and stopped were specifically monitored for development of DAWS by investigators in 10 centers across Europe. The criteria used for development of DAWS were pragmatic and were based on the expert advice and guidelines reported by Rabinak 1 and utilized the use of the NMSQuest, a validated self-reported nonmotor symptoms (NMS) tool addressing 30 NMS. 4 NMSQuest contains questions in a "yes" and "no" format that are described as typical symptoms of DAWS. In addition, in all suspected DAWS

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