Treatment of motor symptoms in Parkinson's disease

Espen Dietrichs; Guido Alves; Espen Benjaminsen; Krisztina Kunszt Johansen; Ole-Bjørn Tysnes

doi:10.4045/tidsskr.22.0804

Clinical review

Treatment of motor symptoms in Parkinson's disease

Norwegian

Espen Dietrichs, Guido Alves, Espen Benjaminsen, Krisztina Kunszt Johansen, Ole-Bjørn Tysnes

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Espen Dietrichs

espen.dietrichs@medisin.uio.no

Department of Neurology

Oslo University Hospital

and

Institute of Clinical Medicine

University of Oslo

Author contributions: first draft of the manuscript, planning, drafting, revision and approval of the manuscript.

Espen Dietrichs, dr.med., professor, senior consultant and specialist in neurology. He represents Southern and Eastern Norway Regional Health Authority in the reference group for the Norwegian Centre for Movement Disorders.

The author has completed the ICMJE form and declares the following conflicts of interest: He has received lecture fees from AbbVie and NordicInfucare.

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Guido Alves

Norwegian Centre for Movement Disorders

Stavanger University Hospital

and

Department of Chemistry, Bioscience, and Environmental Engineering

University of Stavanger

Author contributions: planning, drafting, revision and approval of the manuscript.

Guido Alves, PhD, professor, specialist in neurology, and head of the Norwegian Centre for Movement Disorders.

The author has completed the ICMJE form and declares no conflicts of interest.

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Espen Benjaminsen

Department of Neurology Nordland Hospital Trust, Bodø

and

Faculty of Health Sciences

UiT The Arctic University of Norway

Author contributions: planning, drafting, revision and approval of the manuscript.

Espen Benjaminsen, PhD, senior consultant, specialist in neurology, and associate professor. He represents Northern Norway Regional Health Authority in the reference group for the Norwegian Centre for Movement Disorders.

The author has completed the ICMJE form and declares no conflicts of interest.

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Krisztina Kunszt Johansen

Department of Neurology

Akershus University Hospital

Author contributions: planning, drafting, revision and approval of the manuscript.

Krisztina Kunszt Johansen, PhD, senior consultant and specialist in neurology. She represents Southern and Eastern Norway Regional Health Authority in the reference group for the Norwegian Centre for Movement Disorders.

The author has completed the ICMJE form and declares the following conflicts of interest: She has received funding from Southern and Eastern Norway Regional Health Authority, lecture fees from Sanofi-Aventis, and consultancy fees from AbbVie.

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Ole-Bjørn Tysnes

Department of Neurology and Neuro-SysMed

Haukeland University Hospital

and

Faculty of Medicine

University of Bergen

Author contributions: planning, drafting, revision and approval of the manuscript.

Ole-Bjørn Tysnes, dr.med., professor, senior consultant and specialist in neurology. He represents Western Norway Regional Health Authority in the reference group for the Norwegian Centre for Movement Disorders.

The author has completed the ICMJE form and declares no conflicts of interest.

Article

In recent years, the development of new therapies and improvements in our understanding of older therapies have led to changes in the management of Parkinson's disease. However, current Norwegian and international therapy recommendations present a range of different options as being equally viable. In this clinical review, we propose an updated algorithm for the medical treatment of motor symptoms in Parkinson's disease, based on evidence-based recommendations and our own personal experience and opinions.

The treatment of Parkinson's disease can be complicated. Many different options are available, and deciding how to treat each individual patient can be difficult. The reference group for the Norwegian Centre for Movement Disorders has published treatment recommendations, but these were last updated in 2014 (1). In recent years, many new drugs and treatment methods have become available, and our understanding of the positive and negative effects of both new and older treatments has increased.

New evidence-based recommendations for the treatment of Parkinson's disease have been developed over the last few years in countries including Germany, Sweden and the UK (2–4). These guidelines provide a detailed account of the various treatment options available along with their scientific evidence base; however, they also present a range of different options as being equally viable, even when, in our opinion, there are good clinical reasons to choose one over another. Many treatments have well-established efficacy compared to placebo, but there are few good studies comparing different treatments. These are issues that cannot currently be resolved through evidence-based recommendations, but which can be discussed in a consensus-based process. Based on evidence-based treatment recommendations and our own clinical experience, we present new consensus-based guidance for choosing treatments for motor symptoms at different stages of Parkinson's disease (Figure 1).

Parkinson's disease

Parkinson's disease is a neurodegenerative disorder characterised by motor symptoms in the form of hypokinesia/bradykinesia, plus rigidity and/or resting tremor (5). Many patients also have non-motor symptoms such as sleep problems, autonomic dysfunction, exhaustion/fatigue, pain, depression, and cognitive impairment (6). Motor symptoms result from the loss of dopaminergic neurons in the substantia nigra. Dopaminergic agents therefore play a key role in the treatment of motor symptoms and can also help to some extent with non-motor symptoms.

Our proposed treatment algorithm applies to idiopathic Parkinson's disease, which is by far the most common form of parkinsonism, and which can usually be diagnosed with considerable certainty (5). However, it can occasionally be difficult to distinguish Parkinson's disease from rarer forms of neurodegenerative parkinsonism (7). A symmetrical clinical profile without tremor, as well as early onset of falls, cognitive impairment, and pronounced autonomic dysfunction are red flags that should raise suspicion of atypical parkinsonism.

Dopaminergic treatment is usually much less effective in these disorders than in idiopathic Parkinson's disease. The response to dopaminergic medication thus provides important additional information that can be used in diagnosis, and it may be necessary to escalate treatment with levodopa at an early stage to higher doses than those described in the algorithm for idiopathic Parkinson's disease. In cases where the diagnosis is uncertain, treatment with levodopa at doses of 600–800 mg/day for several months may be required to test medication response.

Initial treatment

There are currently no treatments available that are guaranteed to slow disease progression. Several studies, including a double-blind Norwegian-Danish study (8), have provided evidence for a disease-modifying effect of monoamine oxidase B inhibitors (MAO-B inhibitors), but the interpretation of the results is disputed. MAO-B inhibitors do, however, have a symptomatic effect since they inhibit dopamine metabolism in the brain, thereby increasing dopamine availability in the synaptic cleft. Although the effect is modest, MAO-B inhibitors (selegiline or rasagiline) are included in all evidence-based treatment recommendations as one of several equally valid options for newly diagnosed patients without major functional impairment (2–4).

Symptomatic treatment

Dopaminergic agents (levodopa and dopamine agonists) constitute the most effective symptomatic treatment. There is no evidence to suggest that delaying treatment is beneficial, but there is some uncertainty related to the choice of agent. Levodopa is undoubtedly the most potent oral treatment, but most patients who use levodopa will go on to develop motor fluctuations over time (9, 10). Several studies have shown that such fluctuations occur later in patients who are started on dopamine agonists, with levodopa added when the effect of dopamine agonists alone is no longer sufficient, compared to patients who are started on levodopa monotherapy at gradually increasing doses (11). It has therefore been common practice to recommend dopamine agonists as first-line therapy in younger patients, due to the increased likelihood that these patients will eventually develop motor fluctuations (1, 12).

However, we now propose that levodopa should be used as first-line therapy for most symptomatic patients, irrespective of age. Several factors have led to this change of view. First, levodopa provides faster and better symptomatic relief. This is particularly important for younger patients with respect to maintaining quality of life and ability to work. It has also been shown that the risk of motor fluctuations is very small at doses of levodopa under 600 mg/day (9).

In addition, the use of dopamine agonists increases the risk of non-motor side effects such as visual hallucinations, sleep attacks, and impulse control disorders (gambling addiction, compulsive shopping, eating disorders, hypersexuality). A Norwegian study showed that the odds ratio for having an impulse control disorder was 7.4 in patients with Parkinson's disease who were using only dopamine agonists, 4.6 in those who were using both levodopa and dopamine agonists, and 1.2 in those on levodopa alone (13). Dopamine agonists must therefore be used with caution. Patients should be informed about the risk of impulse control disorders prior to beginning treatment with a dopamine agonist, and it is important to follow up with patients as well as their family to identify any reduction in impulse control during treatment.

If levodopa provides inadequate symptomatic relief, it is often necessary to increase both the total dose and the frequency of levodopa intake. When a patient begins to experience fluctuations that require dosing more than three times a day, it may be appropriate to add a catechol-O-methyltransferase (COMT) inhibitor, such as entacapone or opicapone, to increase the bioavailability of levodopa. Combination therapy with levodopa and dopamine agonists may help counteract motor fluctuations while allowing a lower dose of levodopa to be used than would otherwise be the case, but again it is important to be aware of the risk of impulse control disorders and other non-motor side effects.

Motor fluctuations

After a number of years of treatment with levodopa, many patients experience motor fluctuations in the form of end-of-dose deterioration ('wearing off') and dyskinesias. The first step in addressing these is usually to adjust the dose and frequency of dopaminergic medication, or to begin combination therapy if this has not already been initiated. Patients with troublesome dyskinesias may benefit from amantadine or safinamide (an MAO-B inhibitor, any other MAO-B inhibitor must therefore be discontinued).

Some patients can experience major problems as a result of motor fluctuations, such as rapid-onset episodes of severe bradykinesia (OFF periods). Subcutaneous administration of the dopamine agonist apomorphine via a pen injector works quickly and can be a useful treatment option. Apomorphine has a slightly different receptor profile to other dopamine agonists and is associated with a lower risk of impulse control disorders.

Advanced treatment

As Parkinson's disease progresses, the capacity of the brain to store dopamine gradually decreases. The therapeutic window for levodopa therefore narrows and the risk of motor fluctuations increases. If motor fluctuations become disabling and can no longer be controlled with standard Parkinson's disease medications, advanced therapies using medical technical devices should be considered. The options here are continuous infusion of dopaminergic drugs through a pump or neurosurgical implantation of electrodes for deep brain stimulation (12).

The advantage of pump-delivered therapy is that medication can be administered at a uniform rate, largely avoiding variations in serum concentration and the resulting motor fluctuations. The dopamine agonist apomorphine can be infused subcutaneously, such that no surgical intervention is required at all. Levodopa can be delivered continuously to the small intestine through a percutaneous endoscopic jejunostomy (PEJ) tube, in the form of an intestinal gel containing levodopa and the decarboxylase inhibitor carbidopa (LCIG), or as an intestinal gel containing levodopa, carbidopa and the COMT inhibitor entacapone (LECIG).

Several companies are now testing levodopa for subcutaneous infusion, and such preparations are likely to become available in Norway in the near future (14).

Deep brain stimulation is the most invasive of the advanced therapies, as electrodes must be implanted in the brain – usually in the subthalamic nucleus of the midbrain — and connected to a pulse generator implanted subcutaneously, either in the chest or the abdomen. Deep brain stimulation is also effective against motor fluctuations, and most patients are able to reduce their dopaminergic medication postoperatively (15).

All forms of advanced therapy help to reduce motor fluctuations and thus have overlapping indications. However, due to differences in their risk profiles, the suitability of the various options differs between patients. Specific algorithms can be used to assess which advanced therapy is best suited to an individual patient (12). Where there are several viable alternatives, it is the patient who must ultimately decide which treatment option they would prefer.

More patients should probably be offered advanced therapy than is currently the case. However, not all patients are suitable candidates. Both physical and mental comorbidities can be contraindications, increasing the associated risks and reducing the benefits. For patients with advanced disease and a history of complications and side effects from multiple drugs, levodopa as monotherapy will often be the best option.

Inadequate tremor suppression

In some patients with tremor-dominant Parkinson's disease, it can be difficult to achieve adequate tremor suppression with medication alone. In specific cases where tremor is disabling, neurosurgical treatment may be indicated, usually deep brain stimulation. Electrodes implanted in the subthalamic nucleus can be effective against tremor (15). Another option is to implant electrodes in either the ventral intermediate nucleus (VIM) of the thalamus or the posterior subthalamic area. The latter is often preferred when the indication for surgery is tremor (16), but stimulating this area is not effective against the other motor symptoms of Parkinson's disease.

MRI-guided focused ultrasound ablation can reduce tremor by creating a permanent lesion in the brain (17). This method is most relevant when there are contraindications for deep brain stimulation. The equipment required is not currently available in Norway, and eligible patients must be referred for treatment abroad.

Discussion

This article represents our proposed algorithm for the treatment of the motor symptoms of Parkinson's disease. However, it is essential to keep in mind that symptoms can vary significantly from patient to patient. The top priority must therefore be to treat each patient individually, focusing on whichever symptoms – motor or non-motor – are considered most problematic by the patient themselves.

Given the complex nature of Parkinson's disease and the many treatment options available, we recommend that diagnostics and treatment are carried out mainly in the specialist health service, but in close collaboration with general practitioners and other healthcare providers in the primary care service. It is important to keep in mind that medical treatment is only one aspect of managing the disorder. Education, exercise, social and practical support, and a range of other interdisciplinary activities and measures are also crucial.

This article has been peer-reviewed.

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Deutsche Gesellschaft für Neurologie. Idiopathisches Parkinson-Syndrom. Leitlinien für Diagnostik und Therapie in der Neurologie. Https://dnvp9c1uo2095.cloudfront.net/wp-content/uploads/2013/01/030010_LL_kurzfassung_ips_2016.pdf Accessed 12.2.2023.
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Giladi N, Gurevich T, Djaldetti R et al. ND0612 (levodopa/carbidopa for subcutaneous infusion) in patients with Parkinson's disease and motor response fluctuations: A randomized, placebo-controlled phase 2 study. Parkinsonism Relat Disord 2021; 91: 139–45. [PubMed][CrossRef]
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Comments ( 4 )

Dette kommentarfeltet modereres, men kommentarer blir ikke redaksjonelt behandlet ut over å sikre at de følger retningslinjer for vårt kommentarfelt.

15.06.2023:

Dietrichs og medarbeidere nevner ikke ECT som alternativ under avansert behandling av motoriske symptomer ved Parkinsons sykdom (1). Jeg kan heller ikke se at ECT er nevnt i terapianbefalingene som de viser til.

I 2015 skrev Kellner og Kellner at New England Journal of Medicine nylig hadde publisert et perspektiv på dyp hjernestimulering ved Parkinsons sykdom uten å nevne ECT (2). De påpekte at ECT er vist å ha effekt både på de motoriske kjernesymptomene og de hyppig ledsagende psykiatriske symptomene ved denne sykdommen. De mente at ECT og dyp hjernestimulering burde testes for å avgjøre hvilken behandling som best øker pasientenes livskvalitet.

Effekt av ECT ved Parkinsons sykdom har vært rapportert fra 1950-tallet. I 2021 publiserte Takamiya og medarbeidere en systematisk oversikt og meta-analyse, men inkludert bare studier som hadde brukt numeriske graderingsskalaer (3), og kasus-rapporter med bare én eller to pasienter ble ekskludert. Studiene var publisert i perioden 1981-2018 og inkluderte 129 pasienter fra 13 observasjonsstudier (ni prospektive, fire retrospektive) og én randomisert dobbelt blind studie versus simulert ECT.

ECT ble funnet å bedre motoriske symptomer signifikant i hele gruppen og i subpopulasjonen uten psykiatriske symptomer. Av-faser ble signifikant redusert. Det samme gjaldt depresjon og psykotiske symptomer. Kognitive funksjoner ble også bedret, men etter korreksjon for publikasjons-skjevhet var dette ikke signifikant. ECT kunne trygt og effektiv brukes også hos pasienter med elektroder for dyp hjernestimulering, som slås av under ECT-sesjonene.

Effekten på de motoriske symptomene inntrer raskere enn på de psykiatriske, men varigheten er som regel kortvarig, oftest uker til måneder (3, 4). Vedlikeholds-ECT for Parkinsons sykdom er kort nevnt i en kasusrapport fra 1983. Men Aarsland og medarbeidere var de første som i 1997 beskrev dette grundig (5). En mann og en kvinne, begge 63 år gamle, hadde avtagende effekt av antiparkinsonmidler og var sterkt invalidisert etter henholdsvis 6 og 17 års sykdomsforløp. De hadde god effekt av høyresidig ECT-serier, som imidlertid måtte gjentas pga. tilbakefall. Derfor ble vedlikeholds-ECT gitt med 2-4 ukers intervall. Da publikasjonen ble skrevet hadde den første pasienten fått totalt 57 ECT-sesjoner over 33 måneder, den andre 53 sesjoner over 4 år. De var da fortsatt veldig mye bedre og klarte seg alene hjemme etter 3 og 4 år. De hadde ingen bivirkninger av betydning pga. ECT.

1. Dietrichs E, Alves G, Benjaminsen E et al. Behandling av motoriske symptomer ved Parkinsons sykdom. Tidsskr Nor Legeforen 2023; 143. doi: 10.4045/tidsskr.22.0804
2. Kellner CH, Kellner DA. Deep brain stimulation versus electroconvulsive therapy in Parkinson's disease. J ECT. 2015; 31: 23. doi: 10.1097/YCT.0000000000000213
3. Takamiya A, Seki M, Kudo S et al. Electroconvulsive Therapy for Parkinson's Disease: A Systematic Review and Meta-Analysis. Mov Disord. 2021; 36: 50-8. doi: 10.1002/mds.28335
4. Rosenquist PB, Youssef NA, Surya S et al. When All Else Fails: The Use of Electroconvulsive Therapy for Conditions Other than Major Depressive Episode. Psychiatr Clin North Am. 2018; 41: 355-71. doi: 10.1016/j.psc.2018.04.002
5. Aarsland D, Larsen JP, Waage O et al. Maintenance electroconvulsive therapy for Parkinson's disease. Convuls Ther. 1997; 13: 274-7.

06.07.2023:

Vi setter pris på interessen for vår artikkel om behandling av motoriske symptomer ved Parkinsons sykdom (1). Per Bergsholm mener at elektrokonvulsiv terapi (ECT) bør være med som et alternativ under avansert parkinsonbehandling (2). Han har helt rett i at ECT også kan ha positive effekter på motoriske parkinsonsymptomer. Flere av medforfatterne i vår oversiktsartikkel har sett det hos egne pasienter. Vi mener likevel at ECT ikke kan sidestilles med dyp hjernestimulering eller pumpebehandling som et alternativ til avansert behandling av motoriske symptomer ved Parkinsons sykdom.

Indikasjonen for avansert parkinsonbehandling er som regel enten motoriske fluktuasjoner eller terapiresistent tremor. Hos parkinsonpasienter benyttes ECT vanligvis bare der det foreligger psykiske symptomer som ledd i alvorlig depresjon eller psykose. Som Bergholm påpeker, har enkelte studier også rapportert motorisk bedring hos en subgruppe av parkinsonpasienter uten depresjon. Den eneste tilgjengelige meta-analysen av ECT-behandling ved Parkinsons sykdom refererer til enkelte rapporter som beskriver bedring i terapiresistent tremor og reduksjon av motoriske fluktuasjoner (3). Foreløpig er slike observasjoner gjort bare hos et lite antall pasienter, og konklusjonen fra meta-analysen er at ECT kan være et verdifullt behandlingsalternativ for pasienter med avansert Parkinsons sykdom som har depresjon og/eller psykose. Men de presiserer at det er mangel på undersøkelser med tilstrekkelig kvalitet, og at det er behov for store kontrollerte multisenterstudier for å dokumentere effekten. (3) Helt tilsvarende konklusjon ble trukket i en ny klinisk studie der 15 parkinsonpasienter fikk ECT i 12 sesjoner over seks uker: Undersøkelsen indikerte at ECT potensielt kan være en aktuell behandling for de parkinsonpasientene som har refraktære psykiske symptomer. Men på grunn av den avtagende effekten av ECT anbefalte forfatterne at slike parkinsonpasienter får konvensjonell behandling sammen med periodisk ECT for å sikre et optimalt medisinsk resultat. (4)

Vårt flytskjema gir en oversikt over de best dokumenterte metodene for motorisk parkinsonbehandling. ECT kan være et godt alternativ for parkinsonpasienter som krever intervensjon på grunn av alvorlige psykiske symptomer. Men hittil finnes det ikke tilstrekkelig vitenskapelig grunnlag til at vi kan anbefale ECT som et generelt tilbud til parkinsonpasienter som trenger avansert behandling. Derfor er ECT ikke med blant de anbefalte former for avansert behandling av motoriske symptomer, verken i vår norske anbefaling eller i de internasjonale evidensbaserte terapianbefalingene som er del av grunnlaget for flytskjemaet (1). Og derfor er heller ikke Parkinsons sykdom nevnt i Helsedirektoratets nasjonale faglige retningslinjer om bruk av ECT (5).

Litteratur:

1. Dietrichs E, Alves G, Benjaminsen E et al. Behandling av motoriske symptomer ved Parkinsons sykdom. Tidsskr Nor Legeforen 2023; 143. doi: 10.4045/tidsskr.22.0804

2. Bergsholm P. Elektrokonvulsiv terapi (ECT) ved Parkinsons sykdom. Tidsskr Nor Legeforen 2023; 143.

3. Takamiya A, Seki M, Kudo S et al. Electroconvulsive Therapy for Parkinson's Disease: A Systematic Review and Meta-Analysis. Mov Disord. 2021; 36: 50-8. doi: 10.1002/mds.28335

4. Afshari D, Shakeri J, Khodamoradi M, et al. Efficacy of electroconvulsive therapy in Parkinson’s disease: A clinical trial. Neurosci Lett 2022;772:136449.

5. Nasjonal faglig retningslinje om bruk av elektrokonvulsiv behandling – ECT. Nasjonale faglige retningslinjer IS-2629. Oslo: Helsedirektoratet 2017.

20.09.2023:

Vi har med interesse fulgt diskusjonen mellom Bergsholm og Dietrichs med kolleger vedrørende nytten av elektrokonvulsiv terapi (ECT) ved Parkinson sykdom (1-3). Undertegnede var fagrepresentanter i arbeidsgruppen som utviklet Helsedirektoratets retningslinje for ECT (4). Dietrichs og kolleger skriver at det ikke finnes vitenskapelig grunnlag for å anbefale ECT som et generelt tilbud til parkinsonpasienter som trenger avansert behandling og skriver videre "...derfor er heller ikke Parkinsons sykdom nevnt i Helsedirektoratets nasjonale faglige retningslinjer om bruk av ECT".
Man kan, med denne formuleringen, få inntrykk av at anbefalinger vedrørende ECT og Parkinsons sykdom ble valgt bort på grunn av manglende kunnskapsgrunnlag. Det medfører imidlertid ikke riktighet; Parkinsons sykdom ble ikke drøftet i arbeidet med retningslinjen. Ved en eventuell revisjon, kan ECTs rolle ved Parkinsons sykdom selvfølgelig være et aktuelt område å undersøke nærmere.

Litteratur:
1. Dietrichs E, Alves G, Benjaminsen E et al. Behandling av motoriske symptomer ved Parkinsons sykdom. Tidsskr Nor Legeforen 2023; 143: doi: 10.4045/tidsskr.22.0804
2. Bergsholm P. Elektrokonvulsiv terapi (ECT) ved Parkinsons sykdom. Tidsskr Nor Legeforen 2023; 143: 620-3. doi: 10.4045/tidsskr.22.0804
3. Dietrichs E, Alves G, Benjaminsen E et al. Dietrichs og medarbeidere svarer. Tidsskr Nor Legeforen 2023; 143: 1023. doi: 10.4045/tidsskr.23.0533
4. Helsedirektoratet. Nasjonal faglig retningslinje om bruk av elektrokonvulsiv behandling - ECT. IS-2629. https://www.helsedirektoratet.no/retningslinjer/ elektrokonvulsiv-behandling-ect/ Elektrokonvulsiv%20behandling%20 ECT)%20%E2%80%93%20
Nasjonal%20faglig%20retningslinje.pdf Lest 9.9.2023

20.09.2023:

Aakhus og Luth mener at vi har utrykt oss upresist vedrørende ECT (1). Vi beklager hvis vår kommentar kan misforstås når det gjelder konklusjonene fra Helsedirektoratets arbeidsgruppe for ECT (2). Vårt lille tilleggspoeng var bare at motoriske plager ved Parkinsons sykdom heller ikke er en anbefalt indikasjon i de norske retningslinjene for ECT, uten at vi kjenner begrunnelsen for det (3).
Bakgrunnen for hele denne diskusjonen er at vi i vår artikkel om anbefalt behandling av motoriske symptomer ved Parkinsons sykdom, helt bevisst ikke har nevnt ECT (4). ECT kan ha god effekt på alvorlige og refraktære psykiske symptomer hos parkinsonpasienter, og i slike tilfeller har det også vært observert positiv effekt på motoriske symptomer (5). Men vitenskapelig dokumentasjon vedrørende bruk av ECT til behandling av motoriske symptomer hos parkinsonpasienter uten alvorlige psykiske plager, er svært mangelfull – nærmest fraværende. Vi ønsker derfor å gjenta vår klare konklusjon: ECT er ikke en metode vi kan føre opp som anbefalt behandling for rent motoriske symptomer ved Parkinsons sykdom.

Litteratur:
1. Aakhus E, Luth SM. Upresist av Dietrichs og kolleger om ECT. https://tidsskriftet.no/2023/09/kommentar/upresist-av-dietrichs-og-kolleger-om-ect Lest 20.9.2023
2. Dietrichs E, Alves G, Benjaminsen E et al. Dietrichs og medarbeidere svarer. Tidsskr Nor Legeforen 2023; 143: 1023. doi: 10.4045/tidsskr.23.0533,
3. Helsedirektoratet. Nasjonal faglig retningslinje om bruk av elektrokonvulsiv behandling - ECT. IS-2629. https://www.helsedirektoratet.no/retningslinjer/ elektrokonvulsiv-behandling-ect/ Elektrokonvulsiv%20behandling%20 ECT)%20%E2%80%93%20
Nasjonal%20faglig%20retningslinje.pdf Lest 20.9.2023
4. Dietrichs E, Alves G, Benjaminsen E et al. Behandling av motoriske symptomer ved Parkinsons sykdom. Tidsskr Nor Legeforen 2023; 143: doi: 10.4045/tidsskr.22.0804
5. Takamiya A, Seki M, Kudo S et al. Electroconvulsive Therapy for Parkinson's Disease: A Systematic Review and Meta-Analysis. Mov Disord. 2021; 36: 50-8. doi: 10.1002/mds.28335

This article was published more than 12 months ago and we have therefore closed it for new comments.

Published: 5 May 2023

Tidsskr Nor Legeforen 5 May 2023 Vol. 143.

doi:

10.4045/tidsskr.22.0804

Received 18.12.2022, first revision submitted 11.1.2023, accepted 27.2.2023.

Open access CC-BY-ND
Copyright: The author(s)

Published: 5 May 2023

Tidsskr Nor Legeforen 2023 Vol. 143.

doi: 10.4045/tidsskr.22.0804

Received 18.12.2022, first revision submitted 11.1.2023, accepted 27.2.2023.

Open access CC-BY-ND
Copyright: The author(s)

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Treatment of motor symptoms in Parkinson's disease

Parkinson's disease

Initial treatment

Symptomatic treatment

Motor fluctuations

Advanced treatment

Inadequate tremor suppression

Discussion

Elektrokonvulsiv terapi (ECT) ved Parkinsons sykdom

Er ECT et alternativ ved Parkinsons sykdom?

Upresist av Dietrichs og kolleger om ECT

ECT er ikke anbefalt som parkinsonbehandling

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