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Case study 1 Patient history

Case study 1 Patient history. Female retired farmer, born 1932 1988: pain right shoulder → physiotherapy, analgesics 1991: Parkinson‘s disease diagnosed, good levodopa response Around 1994: motor fluctuations Pergolide added, later → pramipexole

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Case study 1 Patient history

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  1. Case study 1Patient history • Female retired farmer, born 1932 • 1988: pain right shoulder → physiotherapy, analgesics • 1991: Parkinson‘s disease diagnosed, good levodopa response • Around 1994: motor fluctuations • Pergolide added, later → pramipexole • 2005: osteoporotic vertebral fracture → uses sticks for walking

  2. Patient historyTreatment • Dyskinesias: choreatic, peak dose, socially embarrassing & physically disabling • ↑ Entacapone; amantadine: no effect • ‛Off’ time ~3 hours/day • Marked non-motor ‛off‘ symptoms: shoulder / back pain, dysphoria, anxiety • Medication: • ASS 100 mg • Alendronate 70 mg/wk • Levodopa/benserazide 200/50 ½ - ½ - ½ - ¼ - ¼ - ¼ - 0 100/25 CR 1 • Pramipexole 0.7mg 1 – 0 – 1 – 1 – 0 – 0 – 0 • Oxycodone 10 mg ½ - 0 – 0 – 0 – 0 – 0 – ½

  3. Discussion • Q. Which factors should be considered in the next • treatment decision for this patient? • Q. Given the factors considered above, which treatment • would you select?

  4. ResultsBefore apomorphine

  5. ResultsOn subcutaneous apomorphine infusion treatment Initiated February 2006

  6. ResultsCurrent status May 2008 • Apomorphine: Flow rate: 7 mg/h; 14 hours/day • Morning: ½ levodopa/benserazide 200/50 + 1 soluble 100/25 • Bedtime: ½ levodopa/benserazide 200/50 • ¼ levodopa/benserazide 200/50 when required (~ 1/day) • Domperidone 60 mg/day • Oxycodone discontinued; non-motor ‘off’ problems much improved

  7. ResultsCurrent status Permission kindly granted by Dr Regina Katzenschlager

  8. Case study 2Patient history • Social history: head of a department of transportation. Occasional work at night and odd hours. Active recreation activities; fishing, hunting, riding bicycle • PD diagnosis at age 50 • After 1.5 years of L-dopa fluctuations, entacapone started with good effect, but diarrhoea (transient)   • Levodopa/benserazide 125 1½ x 6, cabergoline 6 mg /day, entacapone 200 mg tid  • 2006: mitral insufficiency  cabergoline stopped, pramipexole 1.05 mg tid • Levodopa/benserazide 125 x 7, levodopa/benserazide 62.5 x 4, soluble levodopa/benserazide 62.5 x 1, levodopa/benserazide SR 125 x 1; total L-dopa: 1.05 g / day • Fluctuations, no ‘on’, dystonic pain, slight hyperkinesias

  9. Discussion • Q. Which factors should be considered in the next • treatment decision for this patient? • Q. Given the factors considered above, which treatment • would you select?

  10. Patient historyTreatment • August 2007: Apomorphine pump 6.8 mg/h, reduction of oral medication • August 2009: pump (7.25 mg/h) during waking hours. Fully active at work and with recreation activities. Uses pen if on call and called out in the night, and for dystonic leg cramps

  11. ResultsCurrent status • Sleeps through the night for the first time in years • No ‘off’ periods during waking hours. Feels independent • Medication: • Madopar 125 mg x 4, entacapone 200 mg x 4, Madopar SR 125 mg x 2; • Total L-dopa reduction: 62 % • Side effects: • Small skin nodules

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