HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text Full Text (PDF) Data Supplement Data Supplement Chinese Translation Spanish Translation All Versions of this Article: 01.wnl.0000215250.82576.87v1 66/7/983    most recent Correspondence: Submit a response Alert me when this article is cited Alert me when Correspondence are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pahwa, R. Articles by Weiner, W. J. Search for Related Content PubMed PubMed Citation Articles by Pahwa, R. Articles by Weiner, W. J. Related Collections Parkinson's disease/Parkinsonism

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

Report of the Quality Standards Subcommittee of the American Academy of Neurology

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.), Baltimore.

Address correspondence and reprint requests to the American Academy of Neurology, 1080 Montreal Avenue, St. Paul, MN 55116.

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).

Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Contents for the April 11 issue to find the title link for this article.

Editorial, 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.

Quality Standards Subcommittee Members are listed in appendix E-4 on the Neurology Web site at www.neurology.org.

Approved by QSS July 30, 2005; Practice Committee December 15, 2005; Board of Directors February 23, 2006.

Endorsed by the National Parkinson Foundation and the Parkinson’s Disease Foundation.

Disclosures are provided after the text.

Received August 16, 2005. Accepted in final form February 16, 2006.

This article has been cited by other articles:

				C. H. Waters and J. J. Chen Pharmacologic Options for Treatment of Levodopa-Associated ``Wearing Off'' Journal of Pharmacy Practice, August 1, 2008; 21(4): 254 - 261. [Abstract] [PDF]

				M. Anheim, A. Batir, V. Fraix, M. Silem, S. Chabardes, E. Seigneuret, P. Krack, A.-L. Benabid, and P. Pollak Improvement in Parkinson Disease by Subthalamic Nucleus Stimulation Based on Electrode Placement: Effects of Reimplantation Arch Neurol, May 1, 2008; 65(5): 612 - 616. [Abstract] [Full Text] [PDF]

				W. Simonson, R. A Hauser, and A. H. Schapira Role of the Pharmacist in the Effective Management of Wearing-Off in Parkinson's Disease Ann. Pharmacother., November 1, 2007; 41(11): 1842 - 1849. [Abstract] [Full Text] [PDF]

				C E Clarke Parkinson's disease BMJ, September 1, 2007; 335(7617): 441 - 445. [Full Text] [PDF]

				A. H. V. Schapira Treatment Options in the Modern Management of Parkinson Disease Arch Neurol, August 1, 2007; 64(8): 1083 - 1088. [Full Text] [PDF]

				A. Stefani, A. M. Lozano, A. Peppe, P. Stanzione, S. Galati, D. Tropepi, M. Pierantozzi, L. Brusa, E. Scarnati, and P. Mazzone Bilateral deep brain stimulation of the pedunculopontine and subthalamic nuclei in severe Parkinson's disease Brain, June 1, 2007; 130(6): 1596 - 1607. [Abstract] [Full Text] [PDF]

				B. Thanvi, N. Lo, and T. Robinson Levodopa-induced dyskinesia in Parkinson's disease: clinical features, pathogenesis, prevention and treatment Postgrad. Med. J., June 1, 2007; 83(980): 384 - 388. [Abstract] [Full Text] [PDF]

				J. Jankovic, R. L. Watts, W. Martin, B. Boroojerdi, and for the SP 512 Rotigotine Transdermal System Clini Transdermal Rotigotine: Double-blind, Placebo-Controlled Trial in Parkinson Disease Arch Neurol, May 1, 2007; 64(5): 676 - 682. [Abstract] [Full Text] [PDF]

				B. K. Madras, M. A. Fahey, M. Goulet, Z. Lin, J. Bendor, C. Goodrich, P. C. Meltzer, D. R. Elmaleh, E. Livni, A. A. Bonab, et al. Dopamine Transporter (DAT) Inhibitors Alleviate Specific Parkinsonian Deficits in Monkeys: Association with DAT Occupancy in Vivo J. Pharmacol. Exp. Ther., November 1, 2006; 319(2): 570 - 585. [Abstract] [Full Text] [PDF]

				American Academy of Neurology Practice Parameters: Parkinson Disease Diagnosis and Treatment Journal Watch Neurology, August 1, 2006; 2006(801): 1 - 1. [Full Text]

				R. L. Albin Practice Parameters for Parkinson disease: signposts for clinical research. Neurology, April 11, 2006; 66(7): 966 - 967. [Full Text] [PDF]

				R. L. Albin Practice Parameters for Parkinson disease: signposts for clinical research. Neurology, April 11, 2006; 66(7): 966 - 967. [Full Text] [PDF]