Pahwa R, Factor S A, Lyons K E, Ondo W G, Gronseth G, Bronte-Stewart H, Hallett M, Miyasaki J, Stevens J, Weiner W J
University of Kansas Medical Center, Kansas City, USA.
Neurology. 2006 Apr 11;66(7):983-95. doi: 10.1212/01.wnl.0000215250.82576.87.
To make evidence-based treatment recommendations for the medical and surgical treatment of patients with Parkinson disease (PD) with levodopa-induced motor fluctuations and dyskinesia. To that end, five questions were addressed. 1. Which medications reduce off time? 2. What is the relative efficacy of medications in reducing off time? 3. Which medications reduce dyskinesia? 4. Does deep brain stimulation (DBS) of the subthalamic nucleus (STN), globus pallidus interna (GPi), or ventral intermediate (VIM) nucleus of the thalamus reduce off time, dyskinesia, and antiparkinsonian medication usage and improve motor function? 5. Which factors predict improvement after DBS?
A 10-member committee including movement disorder specialists and general neurologists evaluated the available evidence based on a structured literature review including MEDLINE, EMBASE, and Ovid databases from 1965 through June 2004.
RESULTS, CONCLUSIONS, AND RECOMMENDATIONS: 1. Entacapone and rasagiline should be offered to reduce off time (Level A). Pergolide, pramipexole, ropinirole, and tolcapone should be considered to reduce off time (Level B). Apomorphine, cabergoline, and selegiline may be considered to reduce off time (Level C). 2. The available evidence does not establish superiority of one medicine over another in reducing off time (Level B). Sustained release carbidopa/levodopa and bromocriptine may be disregarded to reduce off time (Level C). 3. Amantadine may be considered to reduce dyskinesia (Level C). 4. Deep brain stimulation of the STN may be considered to improve motor function and reduce off time, dyskinesia, and medication usage (Level C). There is insufficient evidence to support or refute the efficacy of DBS of the GPi or VIM nucleus of the thalamus in reducing off time, dyskinesia, or medication usage, or to improve motor function. 5. Preoperative response to levodopa predicts better outcome after DBS of the STN (Level B).
针对左旋多巴诱发运动波动和异动症的帕金森病（PD）患者的药物及手术治疗，制定基于证据的治疗建议。为此，探讨了五个问题。1. 哪些药物可减少“关”期时间？2. 药物在减少“关”期时间方面的相对疗效如何？3. 哪些药物可减轻异动症？4. 丘脑底核（STN）、内侧苍白球（GPi）或丘脑腹中间核（VIM）的深部脑刺激（DBS）能否减少“关”期时间、异动症及抗帕金森病药物使用并改善运动功能？5. 哪些因素可预测DBS术后改善情况？
一个由10名成员组成的委员会，包括运动障碍专家和普通神经科医生，基于对1965年至2004年6月期间MEDLINE、EMBASE和Ovid数据库的结构化文献综述，对现有证据进行了评估。
结果、结论及建议：1. 应使用恩他卡朋和雷沙吉兰减少“关”期时间（A级）。可考虑使用培高利特、普拉克索、罗匹尼罗和托卡朋减少“关”期时间（B级）。可考虑使用阿扑吗啡、卡麦角林和司来吉兰减少“关”期时间（C级）。2. 现有证据未证实一种药物在减少“关”期时间方面优于另一种药物（B级）。可忽略使用缓释卡比多巴/左旋多巴和溴隐亭减少“关”期时间（C级）。3. 可考虑使用金刚烷胺减轻异动症（C级）。4. 可考虑对STN进行深部脑刺激以改善运动功能并减少“关”期时间、异动症及药物使用（C级）。尚无足够证据支持或反驳对GPi或丘脑VIM核进行DBS在减少“关”期时间、异动症或药物使用或改善运动功能方面的疗效。5. 术前对左旋多巴的反应可预测STN进行DBS术后更好的结果（B级）。
