Product information and disease description Place of product in therapy Approaches to treatment

Care management intervention strategies

14 evidence topics · 6 sources

Counseling and screening before starting a dopamine agonist

“Clinicians should inform the patient and caregiver (when present) of important side effects of dopamine agonists before prescribing; this discussion should specifically include ICDs, excessive daytime sleepiness, sudden-onset sleep, nausea, postural hypotension, and hallucinations.” (opens the source at this quote in a new tab)
“Clinicians should screen patients for cognitive impairment, excessive daytime sleepiness, sudden-onset sleep, hallucinations, orthostatic hypotension, and the presence of risk factors for ICDs before prescribing a dopamine agonist.” (opens the source at this quote in a new tab)

Ongoing monitoring with caregiver involvement and validated questionnaires

“Clinicians should screen patients for the presence of adverse effects related to dopamine agonists, including ICDs, excessive daytime sleepiness, sudden-onset sleep, orthostatic hypotension, cognitive impairment, and hallucinations repeatedly in follow-up of patients prescribed dopamine agonists.” (opens the source at this quote in a new tab)
“Clinicians should involve caregivers in assessments for ICDs, excessive daytime sleepiness, sudden-onset sleep, orthostatic hypotension, cognitive impairment, and hallucinations in patients with PD.” (opens the source at this quote in a new tab)
“Clinicians may screen patients for the presence of adverse effects associated with dopamine agonists using questionnaires validated for this purpose, including the QUIP for ICDs, and the ESS for the assessment of impaired wakefulness.” (opens the source at this quote in a new tab)
“The QUIP and ESS are patient-completed scales with an administration time of less than 10 minutes and are publicly available for clinical use.” (opens the source at this quote in a new tab)

Monitoring during levodopa therapy

“Clinicians should routinely monitor patients taking levodopa for their motor response to treatment, and for the presence of dyskinesia, motor fluctuations, ICDs, excessive daytime sleepiness, postural hypotension, nausea, and hallucinations, to guide dosage titration over time.” (opens the source at this quote in a new tab)

Tapering dopamine agonists after adverse effects

“Clinicians should recommend tapering or discontinuation of dopamine agonists if patients experience disabling medication-related adverse effects, including ICDs, excessive daytime sleepiness, sudden-onset sleep, cognitive impairment, or hallucinations.” (opens the source at this quote in a new tab)
“When dopamine agonists must be discontinued due to adverse effects, clinicians should monitor patients for symptoms of DAWS and, when possible, gradually decrease the dosage to minimize symptoms.” (opens the source at this quote in a new tab)

Tapering dopamine agonists: approach and management of withdrawal syndrome

“There is scarce information or guidelines on how to discontinue DAs.” (opens the source at this quote in a new tab)
“When reducing the DAs dose, the general rule is to individualize the process, reducing in small doses, and with careful observation. Authors suggest even slower tapering than proposed (according to available sources) in Table 3.” (opens the source at this quote in a new tab)
“The implementation of these new methods implicates the reduction or withdrawal of previously used medications. Dopamine agonists are usually the first ones to be reduced. Thus, advanced therapies can be considered as a factor possibly contributing to the development of DAWS” (opens the source at this quote in a new tab)
“A practical conclusion is to cautiously reduce DAs and LD after implementation of advanced therapies. Our suggestion is even to increase this time and prolong the reduction at small steps during the first 6 months after surgery or pump therapy initiation.” (opens the source at this quote in a new tab)
“Therapeutic decision: consider reintroducing DAs (another type and dose), carefully monitor for ICD or other side effects, consider personalized symptomatic treatment, consider non-pharmacologic treatment (psychotherapy, physiotherapy, occupational therapy, psychosocial support).” (opens the source at this quote in a new tab)
“Nevertheless, the most important management is the slow-as-possible tapering of DAs, and only when necessary.” (opens the source at this quote in a new tab)

Tapering dopamine agonists: proposed reduction rates by agent

Dopamine agonist and dose setting	Quoted rate of reduction
Pramipexole, low doses	“At low doses (e.g., ≤ 1.5 mg/d.): reduce by 25–33% every 7–14 days”
Pramipexole, higher doses	“At higher doses (e.g., > 1.5 mg/d.): reduce by 10–25% every 1–2 weeks”
Pramipexole, long-term treatment or impulse control disorder	“Long-term treatment or ICD, the rate 10% every 1–2 weeks”
Pramipexole extended release	“Reduction by 0.375 mg every second day”
Rotigotine	“Reduction by 2 mg every second day, until discontinuation”
Ropinirole immediate release (one of two listed rates)	“2 mg every second day”
Piribedil	“50 mg every third day”
Apomorphine pump	“0.5 mg/h every second day”

Information, review, and management of impulse control disorders

“Discuss potential impulse control disorders at review appointments, particularly when modifying therapy, and record that the discussion has taken place.” (opens the source at this quote in a new tab)
“When managing impulse control disorders, modify dopaminergic therapy by first gradually reducing any dopamine agonist. Monitor whether the impulse control disorder improves and whether the person has any symptoms of dopamine agonist withdrawal.” (opens the source at this quote in a new tab)
“Offer specialist cognitive behavioural therapy targeted at impulse control disorders if modifying dopaminergic therapy is not effective.” (opens the source at this quote in a new tab)

Continuity of medication during hospital or care home admission

“Antiparkinsonian medicines should not be withdrawn abruptly or allowed to fail suddenly due to poor absorption (for example, gastroenteritis, abdominal surgery) to avoid the potential for acute akinesia or neuroleptic malignant syndrome.” (opens the source at this quote in a new tab)
“In view of the risks of sudden changes in antiparkinsonian medicines, people with Parkinson's disease who are admitted to hospital or care homes should have their medicines:” (opens the source at this quote in a new tab)

Nurse specialist, rehabilitation therapy, and nutrition

“People with Parkinson's disease should have regular access to:” (opens the source at this quote in a new tab)
“Offer Parkinson's disease-specific physiotherapy for people who are experiencing balance or motor function problems.” (opens the source at this quote in a new tab)
“Offer Parkinson's disease-specific occupational therapy for people who are having difficulties with activities of daily living.” (opens the source at this quote in a new tab)
“Offer speech and language therapy for people with Parkinson's disease who are experiencing problems with communication, swallowing or saliva.” (opens the source at this quote in a new tab)
“Discuss a diet in which most of the protein is eaten in the final main meal of the day (a protein redistribution diet) for people with Parkinson's disease on levodopa who experience motor fluctuations.” (opens the source at this quote in a new tab)

Physiotherapy and exercise as adjuncts to medication

“For adjunct therapy in optimized PD for general or specific motor symptoms including gait, rivastigmine is possibly useful and physiotherapy is clinically useful; exercise-based movement strategy training and formalized patterned exercises are possibly useful.” (opens the source at this quote in a new tab)

Practical adjustments before adding an adjunct

“In clinical practice, the most common approach is to start by adjusting the dosing schedule of levodopa, which may involve taking more frequent doses throughout the day or shortening the interval between doses.” (opens the source at this quote in a new tab)
“Additionally, promoting the predictability of levodopa absorption is important; this can be achieved by taking it on an empty stomach and ensuring normal gastrointestinal transit time through the treatment of constipation.” (opens the source at this quote in a new tab)

Sequence of interventions for motor fluctuations in clinical practice

“In daily clinical practice, adjusting the timing of levodopa preparations to a shorter time interval and improving absorption, for example, by taking levodopa on an empty stomach and by improving gastrointestinal transit by treating constipation are all partly effective methods.” (opens the source at this quote in a new tab)
“In clinical practice there is a hierarchical use of interventions according to safety risks.” (opens the source at this quote in a new tab)
“Thus, earlier in the course of developing motor fluctuations, the first-line treatments are usually oral (or transdermal) agents (dopaminergics, enzyme inhibitors or nondopaminergics), followed by parenteral and surgical techniques for more advanced patients.” (opens the source at this quote in a new tab)

Palliative care referral

“Consider referring people at any stage of Parkinson's disease to the palliative care team to give them and their family members or carers (as appropriate) the opportunity to discuss palliative care and care at the end of life.” (opens the source at this quote in a new tab)

Caregiver-directed cognitive behavior therapy and palliative care: meta-analysis of effect on caregiver burden

“Meta-analysis showed that cognitive behavior therapy and palliative care had no significant effect to reduce caregiver burden in PD patients’ caregiver.” (opens the source at this quote in a new tab)
“Three articles which used CBT as their intervention reported ZBI score on caregivers” (opens the source at this quote in a new tab)
“The results of meta-analysis showed that there was no significant difference in ZBI between intervention group and control group (MD = − 3.56; 95% CI = − 7.78, 0.66; P = 0.10).” (opens the source at this quote in a new tab)
“Three articles which used palliative care as their intervention reported ZBI score on caregivers” (opens the source at this quote in a new tab)
“The results of meta-analysis showed that there was no significant difference in ZBI between intervention group and control group (MD = − 0.41; 95% CI = − 1.06, 0.24; P = 0.22).” (opens the source at this quote in a new tab)