Parkinson Institute, Istituti Clinici di Perfezionamento, Milan, Italy.
Parkinsonism Relat Disord. 2009 Dec;15 Suppl 4:S97-100. doi: 10.1016/S1353-8020(09)70844-2.
Motor fluctuations and dyskinesia are common in advanced Parkinson's disease and can be poorly managed by current oral medications. Risk factors include the amount of L-dopa administered, gender and patient age. Continuous duodenal L-dopa or subcutaneous apomorphine infusions are helpful strategies because they can control motor complications by providing continuous dopaminergic drug delivery. Apomorphine subcutaneous infusion provides a motor benefit similar to that of dopamine and is relatively easy to use in advanced PD. However, it commonly requires concomitant administration of oral L-dopa and its long-term use is limited by compliance. Continuous administration of L-dopa/carbidopa by infusion in the duodenum/jejunum is a more complex procedure requiring a gastrostomy for the placement of the infusion tube, but it allows replacement of all oral medications and the achievement of a satisfactory therapeutic response paralleled by a reduction of motor complication severity. It should be noted that although these procedures are effective, most evidence relates to small case series and, particularly in the case of apomorphine, despite its long-term availability, there is a complete lack of randomized blinded studies. In addition, unlike deep brain stimulation, it is unclear which patients are the best candidates for these procedures, making any indirect comparison very complex, given the clinical heterogeneity of reported patients. This has consequences in resource allocation and in estimating cost-benefit ratios for these complex therapies in advanced PD.
运动波动和运动障碍在晚期帕金森病中很常见，目前的口服药物治疗效果不佳。风险因素包括给予的左旋多巴剂量、性别和患者年龄。连续十二指肠给予左旋多巴或皮下给予阿朴吗啡输注是有帮助的策略，因为它们可以通过提供持续的多巴胺能药物输送来控制运动并发症。皮下给予阿朴吗啡可提供与多巴胺相似的运动益处，并且在晚期 PD 中相对容易使用。然而，它通常需要同时给予口服左旋多巴，并且其长期使用受到依从性的限制。通过在十二指肠/空肠中输注连续给予左旋多巴/卡比多巴是一种更复杂的程序，需要进行胃造口术以放置输注管，但它允许替代所有口服药物，并实现令人满意的治疗反应，同时降低运动并发症的严重程度。需要注意的是，尽管这些程序有效，但大多数证据仅涉及小病例系列，特别是在阿朴吗啡的情况下，尽管其长期可用，但完全缺乏随机对照研究。此外，与深部脑刺激不同，对于这些程序，哪些患者是最佳候选者尚不清楚，因此，由于报告的患者存在临床异质性，任何间接比较都非常复杂。这对资源分配和估计晚期 PD 中这些复杂治疗的成本效益比产生了影响。
