Aktuelle Neurologie 2018; 45(09): 665-671
DOI: 10.1055/a-0642-1737
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

„Medikamentös ausbehandelte Fluktuationen“ trotz „optimierter peroraler/transdermaler Therapie“ bei Morbus Parkinson: Versuch einer pragmatischen Definition

Medically Refractory Motor Complications in Parkinson’s Disease: Proposal for a Pragmatic Definition
Georg Ebersbach
1   Neurologisches Fachkrankenhaus für Bewegungsstörungen/Parkinson, Neurologie, Beelitz-Heilstätten
,
Werner Poewe
2   Universitätsklinik für Neurologie, Medizinische Universität Innsbruck, Österreich
› Author Affiliations
Further Information

Publication History

Publication Date:
04 July 2018 (online)

Zusammenfassung

Im Verlauf der Behandlung des idiopathischen Parkinson-Syndroms (IPS) kann es dazu kommen, dass L-Dopa-induzierte motorische Komplikationen (Wirkfluktuationen und Dyskinesien) nicht mehr suffizient durch Anpassung der oralen oder transdermalen Medikation beherrschbar sind. Diese Situation wird unter anderem mit dem Begriff „medikamentös ausbehandelte Fluktuationen“ (MAF) umschrieben und bildet den Ausgangspunkt für eskalierende Therapieentscheidungen mit teilweise weitreichender Bedeutung für die Alltagsabläufe, Lebensqualität und Zukunftsperspektiven der betroffenen Patienten und für ihr Umfeld. Nationale und internationale Leitlinien empfehlen, zu diesem Zeitpunkt die (Differenzial-)Indikation für eine der derzeit etablierten eskalierten Therapien mittels tiefer Hirnstimulation (THS), kontinuierlicher subkutaner Apomorphin-Infusion (APO) oder intrajejunaler Infusion von Levodopa-Gel (IJLG) zu prüfen.

Obwohl die Termini „medikamentös ausbehandelte“ bzw. „refraktäre“ Fluktuationen/Dyskinesien intuitiv genauso verständlich erscheinen wie der eng damit verbundene Begriff der „optimierten Medikation“, handelt es sich letztlich um Konstrukte, die in Leitlinien nicht konkret definiert und daher einer subjektiven individuellen Beurteilung anheimgestellt werden. Weil die Feststellung von „MAF“ weitreichende therapeutische Konsequenzen hat, wird in diesem Artikel ein pragmatischer Algorithmus für die Optimierung der Medikation bei Fluktuationen und Dyskinesien vorgestellt, der zur Operationalisierung des Begriffs der MAF beitragen soll. Außerdem soll die Frage diskutiert werden, ob und unter welchen Umständen bei der Indikationsstellung zur THS oder anderen Eskalationstherapien auf eine vorangehende Optimierung der oralen/transdermalen Medikation verzichtet werden kann.

Neben einer methodischen Analyse der vorhandenen therapeutischen Optionen bedeutet die individuelle Festlegung, ab welchem Zeitpunkt Komplikationen der oral-medikamentösen Therapie als nicht mehr tolerabel betrachtet werden, immer auch eine Berücksichtigung der Präferenzen und Bedenken des einzelnen Patienten. Eine pragmatische Definition von MAF ersetzt daher nicht eine individualisierte Entscheidungsfindung für eine eskalierte Therapie im Sinne eines „shared informed decision making“, sondern soll dem Behandler therapeutische Grundregeln für diesen Prozess an die Hand geben.

Abstract

Levodopa-induced response fluctuations and dyskinesias in advanced Parkinson’s disease eventually fail to respond satisfactorily to adjustments of oral or transdermal medications. This situation can be described as “medically refractory motor complications” (MRMC) and requires consideration of advanced therapies that can have fundamental consequences for daily routines, quality of life and future perspectives of patients and their caregivers. Most national and international guidelines list deep brain stimulation (DBS), continuous infusion of apomorphine (APO) or intrajejunal infusion of levodopa-gel (IJLG) in this context. While the terms “medically refractory fluctuations/dyskinesias” or the closely related concept of “optimized medication” are commonly used, there is a lack of operational definitions in current guidelines. Since identification of MRMC has important therapeutic implications, we propose a pragmatic algorithm for the optimization of medication in order to operationalize the definition of MRMC. Furthermore we will discuss whether optimization of oral/transdermal medication should be mandatory before considering DBS or other advanced treatments.

Besides evaluating available options to optimize medical treatment, individual preferences and concerns need to be taken into account when considering tolerability of oral medication and deciding when to start advanced therapies. A pragmatic definition of MRMC does not substitute shared informed decision making but provides methodological guidance for the physician to support this process.

 
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