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Learning objectives

Learning objectives. At the end of this section you will: Have applied the knowledge gained from the earlier sessions to: Understand the impact of pulsatile dopaminergic therapy-induced motor complications on patient functioning

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Learning objectives

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  1. Learning objectives • At the end of this section you will: • Have applied the knowledge gained from the earlier sessions to: • Understand the impact of pulsatile dopaminergic therapy-induced motor complications on patient functioning • Identify which patient types could benefit from the three CDS treatments currently available

  2. Case study 1Patient history • Diagnosed 1986 • His life revolved around taking tablets • Problems with sleep, which had an impact on his quality of life • In 1999, he received carbidopa/levodopa infusion for the first time • A PEG operation was performed in May 2000

  3. Discussion • Q. What additional options are available to further improve the quality of life of this patient?

  4. Results • Since 2002, 24-hour infusion has improved his sleep • Few drawbacks • From having a life dominated by tablet-taking, increasingly severe motor functions and very poor sleep, patient feels that he can once again fill his time with meaningful activities • At the latest follow-up, he described his motor functions and sleep as good

  5. CDS impact on sleep 24-hour infusion – impact on sleep (N=1; PD sleep scale; maximum 150; HY stage 4-5:~90) Adapted from Nyholm et al. Neurology 2005;65: 1506-7

  6. ‘On/off’ mobility chart On/Off mobility chart: conventional treatment versus intraduodenalcarbidopa/levodopa gel infusion Intraduodenalcarbidopa/levodopa gel infusion Anders. Data on file

  7. Conclusions • DBS not suitable due to previous depression • Without pump therapy living alone would not have been possible • Living alone is possible with intraduodenal carbidopa/levodopa gel infusion in some cases • 24-hour infusion of great benefit for this patient

  8. Case study 2Patient history • Male, 58 years old • Occupation: teacher • Parkinson‘s disease since the age of 45, otherwise healthy • Motor fluctuations and dyskinesias since the age of 52

  9. Patient historySymptoms and treatment • 2005 • ‘On-off‘ fluctuations; severe ‘off’ phases with freezing; ‘on’ phases with pronounced dyskinesias • Depressive symptoms • No dementia • Medication: • Pramipexole 1.4 mg daily • Levodopa 525 mg daily • Entacapone 1400 mg daily • Amantadine 200 mg daily • Quetiapine 50 mg daily

  10. Patient historySymptoms and behaviour • Dopamine dysregulation syndrome (DDS) • Went to several doctors for prescriptions • Consumed up to 3 g of levodopa daily • Did not follow advice to restrict medication at all • Punding • Impulse control disorder (ICD) • Hypersexuality • Called sex hotlines • Visited prostitutes daily • Gambling • Lost large parts of personal savings • Dopaminergic psychotic symptoms • Hallucinations • Confusion

  11. Patient historyConsequences of actions • Lost family, home • Legal guardian necessary to control his economy • Nursing home

  12. TreatmentStep 1 • Levodopa monotherapy 800 mg daily • Result: • Psychotic symptoms improved, but did not disappear • DDS and ICD did not change • Motor fluctuations and dyskinesias worsened

  13. TreatmentStep 2 • Quetiapine raised to 200 mg daily • Result • DDS and ICD did not change

  14. Discussion • Q. Considering the results from treatment step 2, which • treatment option would be appropriate for the next • treatment step: • DBS? • Subcutaneous apomorphine infusion? • Intraduodenal carbidopa/levodopa gel infusion? • Other?

  15. TreatmentStep 3 • Treatment: • Intraduodenal carbidopa/levodopa gel infusion 5.2 ml/h daytime, 3.6 ml/h night-time, bolus: 2 ml, max 5 per day • Quetiapine 75 mg daily • All other medication stopped • Result: • DDS resolved almost completely • ICD resolved completely • No psychotic symptoms, no confusion • Cognitive functions normal • Strong improvement of motor fluctuations • Side effects: • Percutaneous endoscopic jejunostomy (PEJ) problems x 2, replaced

  16. Discussion • Q. In your opinion, what was the underlying reason for the • improvements observed with intraduodenal carbidopa/levodopa gel infusion?

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