Case study 1 patient history
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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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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


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


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?


ResultsBefore apomorphine


ResultsOn subcutaneous apomorphine infusion treatment

Initiated February 2006


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


ResultsCurrent status

Permission kindly granted by Dr Regina Katzenschlager


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


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?


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


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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