Opinion
Video
Clinical Insights on Dyskinesia and Tremor in Parkinson Disease
Panelist discusses how distinguishing between dyskinesia (choreiform, dance-like movements) and tremor in Parkinson disease is crucial for treatment decisions, as modern therapeutic options including extended-release amantadine, continuous subcutaneous delivery systems, and advanced formulations can now effectively manage both motor fluctuations and troublesome dyskinesias simultaneously.
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Parkinson disease management presents significant clinical challenges when distinguishing between dyskinesia and tremor, 2 motor symptoms that often appear similar but require distinct treatment approaches. Daniel Kremens, MD, JD; Fernando Pagan, MD; and Yasar Torres-Yaghi, MD, discuss how dyskinesias manifest as uncontrollable, excessive, dance-like (choreiform) movements affecting any part of the body, while tremor presents differently in timing and character. The experts emphasize that patients frequently experience both symptoms simultaneously, with one body part exhibiting dyskinesia while another shows tremor, creating therapeutic dilemmas since treatments that increase “on” time typically exacerbate dyskinesia.
Several key risk factors increase dyskinesia likelihood, including young-onset Parkinson disease, female sex, low body mass index, and daily levodopa doses exceeding 400 to 600 mg. The pathophysiology involves progressive loss of dopaminergic neurons and increasingly pulsatile stimulation from oral levodopa, which leads to postsynaptic receptor remodeling and misfiring. The narrowing therapeutic window over time makes patients more susceptible to both “off” episodes (tremor) and peak-dose dyskinesias, creating complex motor fluctuation patterns that require careful clinical assessment and patient education about symptom recognition.
Contemporary dyskinesia management has evolved beyond the traditional approach of reducing medications or frequent dosing. Current evidence-based treatments include extended-release amantadine (with Level A evidence for reducing dyskinesias while improving on time), long-acting carbidopa-levodopa formulations, and continuous subcutaneous delivery systems for both foslevodopa and apomorphine. Deep brain stimulation remains highly effective, providing up to 4 hours of quality on time. Emerging therapies include next-generation dopamine agonists (D1/D5 and D1/D2 partial agonists) that promise potent efficacy without traditional adverse effects, offering hope for earlier intervention to prevent motor complications.
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