Adjusting and Changing Treatment Regimens in Parkinson Disease

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Treatment Changes and Options for Off Fluctuations

Primary Reasons for Treatment Changes:

• Diminishing efficacy of current regimen
• Emergence/worsening of motor fluctuations and dyskinesias
• Development of adverse effects
• Disease progression affecting nonmotor symptoms
• Cognitive decline affecting medication adherence

Process for Treatment Adjustment:

• Assess pattern and timing of symptoms (symptom diaries)
• Optimize oral levodopa dosing (dose/frequency adjustments)
• Add adjunctive medications strategically
• Consider advanced therapies when oral medications are inadequate
• Regular follow-up to monitor response and adjust as needed

Current Options for Off Fluctuations:

• Levodopa optimization: dose adjustments, controlled-release formulations
• Adjunctive therapies: COMT inhibitors, MAO-B inhibitors, dopamine agonists
• Rescue therapies: apomorphine injection, levodopa inhalation powder, sublingual apomorphine
• Advanced therapies: deep brain stimulation, continuous infusion therapies (levodopa intestinal gel, subcutaneous apomorphine)