Parkinsons disease

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Parkinsons disease

• Dr Mark Silva

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Parkinsons disease
Idiopathic Parkinsons disease parkinsonism
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HVA DOPAC
Pergolide Lysuride Bromocriptine Cabergoline
MAO B
Dopa Decarboxylase
Selegiline Rasagiline
L-DOPA
Madopar Sinemet Duodopa
STALEVO Entacapone Tolcapone
Ropinirole Ropinirole OD Pramipexole Rotigotine Ap
omorphine
COMT
3-O-methyl-DOPA
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Levodopa preparations

• Madopar
• 62.5 50 12.5
• 125 100 25
• 250 200 50
• CR 125 25
• 62.5 dispersible
• 125 dispersible

• Sinemet
• 62.5 50 12.5
• 110 100 10
• plus 100 25
• 275 250 25
• ½ CR 100 25
• CR 200 50
• Carbidopa 70-100mg/day

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Combination
Stalevo Sinemet Entacapone Stalevo-
50 (Sinemet 62.5) Stalevo-100 (Sinemet
plus) Stalevo-150 (Sinemet 275)
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Nice Guidelines

• Referral to expert for accurate diagnosis
• Diagnosis expert review
• Regular access to specialist nursing care.
• Access to Physiotherapy
• Access to OT
• Access to SALT
• Palliative care

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NICE diagnosis early disease

• Use UK PDS Brain Bank Criteria
• Consider I-FP-CIT SPECT
• Specialist review every 6 12 months

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UK PDS clinical diagnostic criteria

• Step 1Diagnosis of parkinsonian syndrome
• Bradykinesia
• one of - muscular rigidity
• - 4-6 Hz rest tremor
• - postural instability

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UK PDS clinical diagnostic criteria

• Step 2 Exclusion criteria for PD
• History of strokes, head injury, encephalitis
• Oculogyric crises
• Neuroleptic treatment
• More than 1 affected relative
• Supranuclear gaze palsy
• Cerebellar signs
• Autonomic involvement or dementia
• Babinski sign
• Cerebral tumour or hydrocephalus
• Negative L-dopa response
• MPTP

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UK PDS clinical diagnostic criteria

• Step 3 Supportive positive criteria for PD
• (3 or more to diagnose definite PD)
• unilateral onset
• rest tremor present
• progressive disorder
• persistent asymmetry
• excellent L-dopa response
• severe L-dopa induced chorea
• L-dopa response for 5 years
• clinical course of 10 years

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NICE - throughout disease

• Non-motor symptoms depression, dementia,
  psychosis, sleep disturbance
• Regular access to specialist care

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NICE - later

• Apomorphine
• STN stimulation
• Thalamic stimulation

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NICE - Neuroprotection

• Vitamin E
• Co-enzyme Q10
• DA agonists
• MAO-B inhibitors

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NICE pharmacotherapy

• Initial L-DOPA. DA agonists, MAO-B inhibitors
• Adjuvant DA agonists, MAO-B inhibitors, COMT
  inhibitors

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NICE

• MR levodopa -X
• Anticholinergics - X
• Amantadine - X
• B- blockers - X

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PD - CDS

• Ropinirole 24 hour OD
• Rotigotine patch
• STALEVO
• Duodopa
• Apomorphine

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HVA DOPAC
Pergolide Lysuride Bromocriptine Cabergoline
MAO B
Dopa Decarboxylase
Selegiline Rasagiline
L-DOPA
Madopar Sinemet Duodopa
STALEVO Entacapone Tolcapone
Ropinirole Ropinirole OD Pramipexole Rotigotine Ap
omorphine
COMT
3-O-methyl-DOPA
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Gloucestershire

• Integration of PD services
• Approval of new drugs
• PD specialist nurses
• Recognise treat non-motor complications
  including depression, sleep, sexual, cognitive
  salivation problems
• Use of therapy services including clinical
  psychology

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there appears to be sufficient reason for
hoping that some remedial process may ere long
be discovered James Parkinson, 1817 An Essay on
the Shaking Palsy.
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PD New stuff

• CDS continuous dopaminergic stimulation
• Compliance
• Non-motor complications of PD

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Rotigotine

• Compliance
• Food interaction
• Swallowing problems
• CDS

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PD vs ET

• PD
• Tremor asymmetry
• Tremor resting
• Chin tremor
• Hypophonia
• Micrographia
• Tone, bradykinesia
• Face gait

• ET
• Tremor symmetry
• Tremor postural
• yes/yes no/no
• Speech - n or tremor
• Handwriting

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PD vs atypical forms

• Tremor 70
• Asymmetry
• Limbsgttrunk
• L-Dopa response
• Dyskinesia

• Tremor 1/3
• Symmetrical
• Trunkgtlimbs
• 1/3 respond
• Early falls
• Postural hypotension

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STALEVO

• STRIDE-PD
• Sinemet vs Stalevo
• Dyskinesia 30 vs 20
• Delay to dyskinesia of 1.5 years

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General conclusions

• DA agonists
• Rasagiline
• Madopar/Sinemet QDS or more
• Stalevo better?
• (Stalevo 50 QDS vs Sinemet plus tds?)
• To patch or not to patch
• Compliance issues

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HVA DOPAC
Pergolide Lisuride Bromocriptine
MAO B
Dopa Decarboxylase
Selegiline
L-DOPA
Carbidopa Benserazide
Entacapone Tolcapone
Ropinirole Pramipexole Cabergoline
COMT
3-O-methyl-DOPA
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Ropinirole 24 hour

• Similar to regular tds Ropinirole
• Compliance likely to improve
• No tolerance

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PD compliance

• Rotigotine patch vs oral medication - better

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Parkinsons diseaseAccuracy of clinical diagnosis
100 cases - 24 not Parkinsons disease
MSA 5 PSNP 6 Alzheimers 3 Alzhe
imers type pathology 3 Vascular 3 Nigral
atrophy without Lewy bodies 2 Postencephalitic
parkinsonism 1 Essential tremor 1
Hughes at al JNNP (1992) 55181-184
76 - 82
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Diagnostic accuracy new data

• ve predictive value
• parkinsoniam 85.3
• IPD 98.6
• other parkinsonisn syndromes 71.4
• Hughes AJ et al
• Brain 2002 (Pt 4)861-870