Change of therapy

Parkinson’s: When tablets no longer help

The progression of Parkinson's disease often requires a change of therapy. An expert explains when this should be done and what treatment options are available.

Parkinson's disease is a chronic neurological disorder. Progressive loss of dopamine-producing nerve cells in the brain leads to motor disorders such as tremors, muscle stiffness and slowness of movement. In the early stages, the symptoms can often be managed well with tablets.

"In the advanced stage, however, many patients experience so-called fluctuations. This means that the effect of the medication diminishes and the patient needs to take more and more medication over the course of the day to control the symptoms," explains neurologist Doz. Dr. Thomas Foki, Head of the Parkinson's Outpatient Clinic at the UK Tulln (Lower Austria).

The alternating phases of good mobility ("on") and severe movement restrictions ("off") are stressful for those affected and make daily life planning difficult. Uncontrolled excessive movements are also typical of advanced Parkinson's. How can patients, relatives or even the doctor treating them recognize when the time has come for a different treatment option?

Time for a new treatment option 
Doz. Foki: "Serious signs are, for example, when the patient is less mobile in the morning than usual. Some sufferers also tend to tremble and sometimes show non-motor disorders such as tiredness, depressed mood or slowed thinking until the next tablet kicks in."

The first measure is always to try to optimize oral drug treatment. If tablets alone are no longer sufficient, modern, so-called device-based therapies can be useful.

Neurologe Doz. Dr. Thomas Foki

Bild: Daniel Auer

The so-called 5-2-1 rule is often used to determine whether a patient is at an advanced stage of Parkinson's disease. This is based on the presence of one of these criteria: 

• The patient requires at least 5 daily doses of the medication (levodopa)
• or there are off-phases for at least 2 hours a day
• or excessive movements occur for at least 1 hour a day. 

Various systems are used 
"The first measure is always to try to optimize oral drug treatment. If tablets alone are no longer sufficient, so-called device-based therapies can be useful," says Doz. Foki. These include

Pumps with subcutaneous drug application are worn on the body; the drug (levodopa-based or apomorphine) is administered directly into the subcutaneous fatty tissue via a catheter. "Previously, with these pump systems, medication was only administered continuously during the day and at night if there were severe problems at night. The needle had to be changed daily. Another system, which administers the drug levodopa, now requires less frequent needle changes and the pump runs 24 hours a day. Two flow rates can be set - higher flow for the day, lower for the night."

Other options include other externally worn pumps in which levodopa is administered evenly into the small intestine using a PEG tube.

Finally, deep brain stimulation is also used. Here, the neurosurgeon inserts electrodes into certain areas of the brain, which emit electrical impulses via a pacemaker placed under the skin. This can alleviate symptoms such as tremors, stiffness and slowness of movement. The invasive method is only suitable for patients who are not older than 70 and do not yet have any mental limitations.

Many factors play a role in the treatment decision, but the patient's needs always take center stage, as Doz. Foki emphasizes.