Levodopa-related dyskinesias and motor fluctuations

Introduction
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By Stephen T Gancher MD

The long-term management of Parkinson disease is commonly accompanied by the development of motor fluctuations and drug-induced dyskinesias. These motor complications present a major challenge in the effective management of this disease. In this clinical article, Dr. Gancher of Oregon Health Sciences University discusses a number of recent studies that clarify the understanding of changes in basal ganglia metabolism underlying these motor effects. In addition, a number of recent treatment advances, including updated information on a recent trial comparing different deep brain stimulation targets and surgical treatment options are outlined.

Key Points

  • In most patients, long-term treatment of Parkinson disease with levodopa is complicated by the gradual emergence of dyskinesias and motor fluctuations.
  • Medical treatment options for dyskinesias and fluctuations are aimed at producing a more stable delivery of drugs to the brain. These include readjustment of levodopa doses and timing, drugs that inhibit levodopa or dopamine metabolism (COMT and MAO-B inhibitors), dopamine agonists, and restriction of dietary protein.
  • In patients with severe dyskinesias or motor fluctuations, deep brain stimulation is generally more effective than medication adjustments.
  • Pallidal and subthalamic stimulation produce roughly equal benefits in motor function, dyskinesias, and quality of life.