Advanced Treatment Options in Parkinson Disease

EP: 1.Off Fluctuations in Parkinson Disease

EP: 2.Adjusting and Changing Treatment Regimens in Parkinson Disease

EP: 3.Recognition of Off Episodes in Parkinson Disease

EP: 4.Conversations About Off Time In Patients With Parkinson Disease

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EP: 5.Advanced Treatment Options in Parkinson Disease

EP: 6.Adjunctive Treatments and Apomorphine for Treatment of Parkinson Disease

EP: 7.Continuous Subcutaneous Apomorphine Infusion (CSAI) and TOLEDO Study in Parkinson Disease

EP: 8.CSAI and INFUS-ON Study for Treatment of Parkinson Disease

EP: 9.Continuous Subcutaneous Infusion Systems for Parkinson Disease and Patient Selection Criteria

EP: 10.Place of Continuous Subcutaneous Infusion Systems in Parkinson Disease Management

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Advanced Treatment Considerations and Challenges

Timing for Advanced Treatment Consideration:

• When standard oral medications fail to adequately control motor fluctuations
• When optimal oral therapy causes intolerable adverse effects
• When quality of life is significantly impacted despite medication optimization
• Usually 5 to 10 years into disease course
• When off time exceeds 2 hours daily despite optimization

Challenges With Current Treatment Options:

• Narrow therapeutic window of levodopa (balancing efficacy vs dyskinesias)
• Pharmacokinetic limitations of oral medications
• Gastrointestinal dysfunction affecting medication absorption
• Cognitive decline limiting complex medication regimens
• Peripheral adverse effects (orthostasis, nausea, impulse control disorders)
• Patient adherence to complex regimens
• Surgical interventions: patient selection criteria, resource limitations, expertise availability
• Cost and insurance coverage barriers for advanced therapies