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Update: Treatments for Motor Symptoms of Parkinson's Disease

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Update: Treatments for Motor Symptoms of Parkinson's Disease RESEARCH ARTICLES The Movement Disorder Society Evidence-Based Medicine Review Update: Treatments for the Motor Symptoms of Parkinson’s Disease Susan H. Fox, MRCP (UK), PhD,1* Regina Katzenschlager, MD,2 Shen-Yang Lim, MD, FRACP,3 Bernard Ravina, MD, MS,4 Klaus Seppi, MD,5 Miguel Coelho, MD,6 Werner Poewe, MD,5 Olivier Rascol, MD, PhD,7 Christopher G. Goetz, MD,8 and Cristina Sampaio, MD, PhD6 1Movement Disorder Clinic, Toronto Western Hospital, Toronto, Ontario, Canada 2Department of Neurology, Danube Hospital/SMZ-Ost, Vienna, Austria 3Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 4Department of Neurology, University of Rochester School of Medicine, Rochester, New York, USA 5Department of Neurology, University Hospital, Innsbruck, Austria 6Neurological Clinic Research Unit, Institute of Molecular Medicine, Lisbon School of Medicine, Lisbon, Portugal 7Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France 8Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA ABSTRACT: The objective was to update previous dopa was likely efficacious in the treatment of motor evidence-based medicine reviews of treatments for motor complications, but the practice implication is investiga- symptoms of Parkinson’s disease published between 2002 tional. Entacapone was nonefficacious as a symptomatic and 2005. Level I (randomized, controlled trial) reports of adjunct to levodopa in nonfluctuating patients and noneffi- pharmacological, surgical, and nonpharmacological inter- cacious in the prevention/delay of motor complications. ventions for the motor symptoms of Parkinson’s disease Rasagiline conclusions were revised to efficacious as a between January 2004 (2001 for nonpharmacological) and symptomatic adjunct, and as treatment for motor fluctua- December 2010 were reviewed. Criteria for inclusion, clini- tions. Clozapine was efficacious in dyskinesia, but cal indications, ranking, efficacy conclusions, safety, and because of safety issues, the practice implication is possi- implications for clinical practice followed the original pro- bly useful. Bilateral subthalamic nucleus deep brain stimu- gram outline and adhered to evidence-based medicine lation, bilateral globus pallidus stimulation, and unilateral methodology. Sixty-eight new studies qualified for review. pallidotomy were updated to efficacious for motor compli- Piribedil, pramipexole, pramipexole extended release, ropi- cations. Physical therapy was revised to likely efficacious nirole, rotigotine, cabergoline, and pergolide were all effica- as symptomatic adjunct therapy. This evidence-based cious as symptomatic monotherapy; ropinirole prolonged medicine review updates the field and highlights gaps for release was likely efficacious. All were efficacious as a research. VC 2011 Movement Disorder Society symptomatic adjunct except pramipexole extended release, for which there is insufficient evidence. For pre- Key Words: Parkinson’s disease; evidence-based vention/delay of motor fluctuations, pramipexole and medicine; levodopa; dopamine agonists; monoamine cabergoline were efficacious, and for prevention/delay of oxidase inhibitors; catechol-O-methyl transferase inhibi- dyskinesia, pramipexole, ropinirole, ropinirole prolonged tors; amantadine; anticholinergics; clozapine; neurosur- release, and cabergoline were all efficacious, whereas per- gery; deep brain stimulation; exercise; physical therapy; golide was likely efficacious. Duodenal infusion of levo- speech therapy; occupational therapy; acupuncture ------------------------------------------------------------ *Correspondence to: Susan H. Fox, Movement Disorder Clinic, Toronto Western Hospital, 399, Bathurst St, Toronto, ON, Canada M5V 2S8; [email protected] Reviewed and approved by the International Executive Committee of the The available treatment options for Parkinson’s dis- Movement Disorder Society. ease (PD) continue to expand. For the practicing clini- Funding agencies: This work was supported by the MDS and an unrestricted educational grant from Teva Pharmaceuticals. cian, the best option for an individual patient may Relevant conflicts of interest/financial disclosures: Nothing to report. seem daunting and confusing. Many drugs have been Full financial disclosures and author roles may be found in the online developed for similar indications—for example, sev- version of this article. eral dopamine agonists are now available—and the de- Received: 3 February 2011; Accepted: 13 May 2011 Published online in Wiley Online Library (wileyonlinelibrary.com). cision as to which drug should be used may not DOI: 10.1002/mds.23829 always be apparent. In addition, many aspects of PD, S2 Movement Disorders, Vol. 26, No. S3, 2011 TREATMENT OF MOTOR SYMPTOMS IN PD in particular, the nonmotor features, may not have • In most cases, articles were only selected for effective treatment options. One mechanism of assist- review that had: ing clinicians in decision making is the use of evi- • an established rating scale or well-described dence-based medicine (EBM). EBM is a strategy for outcome measurement of end points; the critical evaluation and uniform comparison of clin- • a minimum of 20 subjects who were treated ical trial data with conclusions based on predeter- for a minimum duration of 4 weeks and that 1 mined efficacy criteria. The process of EBM has were reported in full-paper format in English. become a key part of health policy in many fields.2 In clinical practice, EBM offers one set of data that must In cases where these criteria were not applied, spe- be integrated with the physician’s experience and judg- cial exceptions were noted with a justification for ment, patient preference, expert opinion, and medical inclusion. economic determinants to arrive at a final therapeutic A quality assessment for each article was calculated recommendation. EBM reviews also help to identify using predetermined criteria described in the original areas where specific evidence is lacking so future review.3 Each intervention was considered for the fol- research can focus on unmet needs. lowing indications: prevention/delay of clinical progres- The Movement Disorder Society (MDS) has already sion, symptomatic monotherapy, symptomatic adjunct performed 2 EBM reviews of treatments for PD. In therapy to levodopa, prevention/delay of motor compli- 2002, the first detailed EBM analysis of pharmacologi- cations (motor fluctuations and dyskinesia), treatment cal, surgical, and psychosocial interventions in the of motor complications (motor fluctuations and dyski- treatment of PD, including nonmotor aspects such as nesia) (Table 1). In contrast to the previous EBM depression, psychosis, and autonomic dysfunction, was reviews, efficacy conclusions were drawn for the pre- 3 published. In 2005 this review was updated with a vention and treatment of motor complications, specifi- focus on the pharmacological and surgical aspects of cally separated into dyskinesia and motor fluctuations. 4 PD. Since 2002, the MDS has sponsored educational For treatments for which there were no new level I events to disseminate this information to clinicians in studies evaluating the separate outcomes of fluctuations order to broaden the applicability of these guidelines to and dyskinesia, if the prior designation of ‘‘insufficient daily practice. This current report updates the previous data’’ had been used for the assessment of motor com- reviews and incorporates new data on (1) efficacy, (2) plications, the conclusion in this report retained ‘insuffi- safety, and (3) implications for clinical practice of treat- cient evidence’ for both dyskinesia and fluctuations. ments for motor symptoms of PD published from Janu- In addition, the terminology has been altered from ary 2004 (2001 for nonpharmacological studies) to ‘‘prevention’’ to ‘‘prevention/delay’’ to reflect the pos- December 2010. A separate publication will focus on sibility that treatments may have a delaying effect, updates in treatments of nonmotor aspects of PD rather than an ability to truly prevent disease progres- (updated from 2002). (NB: Studies available as ‘‘EPub sion or motor complications. ahead of print’’ up to December 2010 are included; as For each intervention, there is a description of the such, full publication dates may be cited as 2011.) new clinical trials followed by a summary with con- clusions. In addition, the conclusions are summarized in Tables 2–8. Each table covers efficacy, safety, and Materials and Methods implications for clinical practice, as defined in Table 1, for each of the above indications. Changes from the The search strategy, inclusion criteria, and evalua- 2005 review listed are indicated by a gray background tion methods followed those previously reported.3,4 with italicized text, and conclusions that have not Literature searches were undertaken for articles pub- changed are listed with a white background. lished between January 2004 (2001 for nonpharmaco- logical therapies) and December 2010, using electronic databases including Medline and the Cochrane Library Results central database and systematic checking of reference lists published in review articles and other clinical Dopamine Agonists reports. The following inclusion criteria were adhered The following dopamine agonists are presented in to. alphabetical order. Twenty-three new studies5–27 were published. New • Randomized controlled trials (RCTs) in idiopathic studies updated efficacy conclusions for the nonergo- PD that measured motor symptoms as the end line dopamine
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