The Movement Disorder Society Evidence‐Based Medicine Review Update: Treatments for the motor symptoms of Parkinson's disease

Abstract

The objective was to update previous evidence-based medicine reviews of treatments for motor symptoms of Parkinson's disease published between 2002 and 2005. Level I (randomized, controlled trial) reports of pharmacological, surgical, and nonpharmacological interventions for the motor symptoms of Parkinson's disease between January 2004 (2001 for nonpharmacological) and December 2010 were reviewed. Criteria for inclusion, clinical indications, ranking, efficacy conclusions, safety, and implications for clinical practice followed the original program outline and adhered to evidence-based medicine methodology. Sixty-eight new studies qualified for review. Piribedil, pramipexole, pramipexole extended release, ropinirole, rotigotine, cabergoline, and pergolide were all efficacious as symptomatic monotherapy; ropinirole prolonged release was likely efficacious. All were efficacious as a symptomatic adjunct except pramipexole extended release, for which there is insufficient evidence. For prevention/delay of motor fluctuations, pramipexole and cabergoline were efficacious, and for prevention/delay of dyskinesia, pramipexole, ropinirole, ropinirole prolonged release, and cabergoline were all efficacious, whereas pergolide was likely efficacious. Duodenal infusion of levodopa was likely efficacious in the treatment of motor complications, but the practice implication is investigational. Entacapone was nonefficacious as a symptomatic adjunct to levodopa in nonfluctuating patients and nonefficacious in the prevention/delay of motor complications. Rasagiline conclusions were revised to efficacious as a symptomatic adjunct, and as treatment for motor fluctuations. Clozapine was efficacious in dyskinesia, but because of safety issues, the practice implication is possibly useful. Bilateral subthalamic nucleus deep brain stimulation, bilateral globus pallidus stimulation, and unilateral pallidotomy were updated to efficacious for motor complications. Physical therapy was revised to likely efficacious as symptomatic adjunct therapy. This evidence-based medicine review updates the field and highlights gaps for research.

Rotigotine polyoxazoline conjugate SER‐214 provides robust and sustained antiparkinsonian benefit

“…Rotigotine was chosen as the candidate molecule for development since it is one of the most potent D2/D3 non-ergot agonists currently used clinically with proven safety and efficacy records in PD patients. 17,19,28 Rotigotine has essentially no oral bioavailability and is currently administered through the use of a daily transdermal patch. However, the patch often results in skin reactions and may fall off prematurely, leading to issues with patient compliance.…”

Parkinsonian Syndromes

“…Levodopa (in combination with a dopa decarboxylase inhibitor) is more efficacious but requires dosing intervals of 3 times per day initially. 16 The dose adjustments of dopamine agonists and levodopa preparations are made in response to clinical effect, emerging symptoms, and side effects. The risk of psychiatric side effects and dyskinesias is greater at higher doses, so a rule of thumb is to treat with the lowest dose possible to achieve benefits for the patient in terms of function and quality of life.…”

Subthalamotomy in the treatment of Parkinson's disease: clinical aspects and mechanisms of action

“…54,165 Paradoxically, a recent study demonstrated that neurosurgeons performed subthalamotomies as often as pallidotomies or thalamotomies in most or all of their cases. 85,145 It was shown that lesioning was more often offered to patients in countries with lower economical development or when patients financed their own surgeries.…”