Idiopathisches Parkinson-Syndrom - Update: Pharmaka, aktivierende Therapien und tiefe Hirnstimulation

Abstract

Two non-ergot dopamine agonists, rotigotine (Neupro®) the first transdermal patch in Parkinson's disease (PD), and piribedil (Clarium®) have been licensed in Germany since 2007 for mono- and levodopa combination therapy. Ropinirole 24-hour prolonged release (Requip® Monotab), another non-ergot dopamine agonist, will be introduced and allow once daily dosing of ropinirol. The non-ergot parenteral dopamine agonist apomorphine available as penject for on demand use or for continuous subcutaneous infusion in patients with off-phases has an important role in patients with in complex motor fluctuations, also for those waiting for deep brain stimulation. Levodopa is still the gold standard in PD therapy. The COMT inhibitors entacapone (Comtess® or in Stalevo® as triple combination with levodopa/carbidopa) and tolcapone (Tasmar®) work only by increasing the bioavailability of levodopa and are helpful for wearing-off phenomena. Levodopa/carbidopa as a gel (Duodopa®) for continuous dudodenal infusion via PEG represents an alternative to the apomorphine pump for seleceted patients. Furthermore, in 2005 a new MAO-B inhibitor, rasagiline (Azilect®), was licensed for all PD stages and in 2007 a cholinesterase inhibitor rivastigimin (Exelon®) for PD associated dementia. However, essential quality of life determining parkinsonian symptoms such as falls, voice and swallowing symptoms are difficult to treat despite the many new drugs and deep brain stimulation (DBS). New activating therapy concepts are emerging for medication and DBS refractory symptoms, which will be increasingly evidence based such as the Lee Silverman Voice Treatment (LSVT®) and the repetitive training of compensatory steps. In DBS of the subthalamic nucleus there is a trend to operate in earlier stages of the disease course than before as the magnitude of postoperative quality of life improvement occurs mainly in young patients.