Practice Parameter: Treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review)

Objective: To make evidence-based treatment recommendations for the medical and surgical treatment of patients with Parkinson disease (PD) with levodopa-induced motor fluctuations and dyskinesia. To that end, five questions were addressed. 1. Which medications reduce off time? 2. What is the relative efficacy of medications in reducing off time? 3. Which medications reduce dyskinesia? 4. Does deep brain stimulation (DBS) of the subthalamic nucleus (STN), globus pallidus interna (GPi), or ventral intermediate (VIM) nucleus of the thalamus reduce off time, dyskinesia, and antiparkinsonian medication usage and improve motor function? 5. Which factors predict improvement after DBS? Methods: A 10-member committee including movement disorder specialists and general neurologists evaluated the available evidence based on a structured literature review including MEDLINE, EMBASE, and Ovid databases from 1965 through June 2004. Results, Conclusions, and Recommendations: 1. Entacapone and rasagiline should be offered to reduce off time (Level A). Pergolide, pramipexole, ropinirole, and tolcapone should be considered to reduce off time (Level B). Apomorphine, cabergoline, and selegiline may be considered to reduce off time (Level C). 2. The available evidence does not establish superiority of one medicine over another in reducing off time (Level B). Sustained release carbidopa/levodopa and bromocriptine may be disregarded to reduce off time (Level C). 3. Amantadine may be considered to reduce dyskinesia (Level C). 4. Deep brain stimulation of the STN may be considered to improve motor function and reduce off time, dyskinesia, and medication usage (Level C). There is insufficient evidence to support or refute the efficacy of DBS of the GPi or VIM nucleus of the thalamus in reducing off time, dyskinesia, or medication usage, or to improve motor function. 5. Preoperative response to levodopa predicts better outcome after DBS of the STN (Level B). NEUROLOGY 2006;66:983–995 Statement of purpose. The Quality Standards Subcommittee (QSS) develops scientifically sound, clinically relevant practice parameters to aid in the practice of neurology. This article addresses medical and surgical treatments for the management of patients with Parkinson disease (PD) with levodopaEditorial, see page 966 See also pages 968, 976, and 996 This article was previously published in electronic format as an Expedited E-Pub at www.neurology.org. From the University of Kansas Medical Center (R.P., K.E.L., G.G.), Kansas City; Emory University School of Medicine (S.A.F.), Atlanta, GA; Baylor College of Medicine (W.G.O.), Houston, TX; Stanford University Hospital (H.B.-S.), San Francisco, CA; National Institutes of Health (M.H.), Bethesda, MD; Toronto Western Hospital (J.M.), Canada; Fort Wayne Neurological Center (J.S.), Fort Wayne, IN; and University of Maryland School of Medicine (W.J.W.),