PracticeUpdate Neurology June 2019

EDITOR’S PICKS 12

Subthalamic Stimulation, Apomorphine, and Levodopa Infusion Have Distinct Effect Profiles in Parkinson’s Disease Movement Disorders Take-home message • The authors of this prospective, nonrandomized, observational, multicenter, international, real-life cohort study with a 6-month follow-up period evaluated the effectiveness of undergoing one of three procedures: deep-brain stimulation of the subthalamic nucleus (STN-DBS) or other targets; intrajejunal levodopa infusion (IJLI); and apomorphine infusion (APO) in patients with Parkinson’s disease (PD). They found that PDQuestionnaire-8, UPDRS-IV, and Non-Motor Symptoms Scale (NMSS) total scores improved significantly at follow-up in all groups. The levodopa equivalent daily dose was reduced by 52% in the DBS group, but not in the other two groups. No differences were found in the motor scores. Treatments had different profiles in terms of effect on NMSS scores: DBS improved urinary/sexual function, mood/cognition, and sleep/fatigue; IJLI improved mood/cognition, sleep/fatigue, and gastrointestinal symptoms; and APO improved mood/cognition, perceptual problems/hallucinations, and attention/memory. Serious adverse events occurred in 6.9% of STN patients, 12.1% of IJLI patients, and 10.3% of APO patients. In the immediate postoperative period, nonserious adverse events, in particular abdominal pain and gastrointestinal symptoms, were found more frequently in the IJLI group. • DBS, IJLI, and APO appear to have distinct effects on motor and non-motor symptoms in patients with PD, and patients would benefit from personalized assessment to determine which treatment is best for them. Codrin Lungu MD Abstract

Outcome changes were analyzed with Wilcoxon signed-rank or paired t test when parametric tests were applicable. Multiple comparisons were corrected (multiple treatments/scales). Effect strengths were quantified with relative changes, effect size, and number needed to treat. Analyses were computed before and after propensity score matching, balancing demo- graphic and clinical characteristics. RESULTS In all groups, PDQuestionnaire-8, UPDRS-IV, and NMSS total scores improved significantly at follow-up. Levodopa equiva- lent daily dose was significantly reduced after STN-DBS. Explorative NMSS domain analyses resulted in distinct profiles: STN-DBS improved urinary/sexual functions, mood/cognition, sleep/ fatigue, and the miscellaneous domain. IJLI improved the 3 latter domains and gastrointes- tinal symptoms. APO improved mood/cognition, perceptual problems/hallucinations, attention/ memory, and the miscellaneous domain. Over- all, STN-DBS and IJLI seemed favorable for NMSS total score, and APO favorable for neu- ropsychological/neuropsychiatric NMS and PDQuestionnaire-8 outcome. CONCLUSIONS This is the first comparison of qual- ity of life, nonmotor. and motor outcomes in PD patients undergoing STN-DBS, IJLI, and APO in a real-life cohort. Distinct effect profiles were identified for each treatment option. Our results highlight the importance of holistic nonmotor and motor symptoms assessments to person- alize treatment choices. EuroInf 2: Subthalamic Stimulation, Apomor- phine, and Levodopa Infusion in Parkinson’s Disease. Mov Disord 2019 Mar 01;34(3)353-365, HS Dafsari, P Martinez-Martin, A Rizos, et al. www.practiceupdate.com/c/81368

international, real-life cohort observation study of 173 PD patients undergoing STN-DBS (n = 101), IJLI (n = 33), or APO (n = 39) were fol- lowed-up using PDQuestionnaire-8, NMSScale (NMSS), Unified PD Rating Scale (UPDRS)-III, UPDRS-IV, and levodopa equivalent daily dose (LEDD) before and 6 months after intervention.

OBJECTIVE Real-life observational report of clin- ical efficacy of bilateral subthalamic stimulation (STN-DBS), apomorphine (APO), and intrajejunal levodopa infusion (IJLI) on quality of life, motor, and nonmotor symptoms (NMS) in Parkinson’s disease (PD). METHODS In this prospective, multicenter,

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