Invasive Therapien bei fortgeschrittener Parkinson-Krankheit: Was wann für wen?

 

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Zusammenfassung

Neben der herkömmlichen Pharmakotherapie haben sich in den letzten Jahren 3 nicht orale Therapiemethoden bei der Parkinson-Krankheit etabliert. Diese sind in Erwägung zu ziehen, wenn aufgrund von motorischen Fluktuationen oder Unverträglichkeiten mit ausschließlich oraler und/oder transdermaler Pharmakotherapie keine stabile motorische Verfügbarkeit im Tagesverlauf mehr gesichert werden kann. Apomorphin zur subkutanen Applikation als Einmalinjektion oder zur kontinuierlichen subkutanen Infusion stellt die am wenigsten invasive Option dar, ist deren Anpassung doch nicht mit einer Operation verbunden. Als potentester Dopaminagonist ist Apomorphin jedoch grundsätzlich mit dem typischen Risiko- und Nebenwirkungsprofil dieser Substanzklasse, wie z. B. Psychosen und Impulskontrollstörungen, verbunden. Die kontinuierliche intrajejunale Instillation von Levodopa über eine Pumpe empfiehlt sich als Alternative für die Patienten, die eine Apomorphintherapie nicht (mehr) tolerieren oder die durch zusätzliche Schluckstörungen ohnehin zur Sicherung der Ernährungssituation und weiterer Medikamentengaben eine Ernährungssonde benötigen. Da diese Therapie mit der Anlage einer perkutanen endoskopischen Gastrojejunostomie (PEG/PEJ) verbunden ist, hat sie eine höhere Invasivität als die Apomorphintherapie. Die Vorteile liegen in der Substanz Levodopa als Monotherapie. Dies ist vor allem für ältere Parkinson-Patienten mit kognitiven Defiziten und Psychoserisiko sowie den o. g. Schluckstörungen von Vorteil. Insbesondere für jüngere, kognitiv intakte Betroffene, die das Stigma und die körperlichen Einschränkungen durch eine Pumpe scheuen, bietet sich die tiefe Hirnstimulation als Alternative an. Für diese invasivste der hier vorgestellten Therapien gelten sorgfältig zu beachtende Ein- und Ausschlusskriterien. Als einzige der 3 hier vorgestellten Methoden gibt es für diese Therapie eine evidenzbasierte Empfehlung zum Einsatz in frühen bis mittleren Krankheitsphasen bei nicht dementen Patienten sobald Fluktuationen auftreten. Die THS-Indikation ist begrenzt durch ein Alter über 70 und Levodopa-resistente Störungen. Für alle 3 Therapien gilt, dass sowohl die Anpassung als auch die Überwachung von diesbezüglich erfahrenen Ärzten geleistet werden sollte.

Abstract

Over the past years three invasive therapies have become available for patients with advanced Parkinson’s disease (PD), when conventional pharmacotherapy can no longer guarantee stable motor performance. Subcutaneous injections or continuous infusions of apomorphine are the least invasive of the three methods presented here as there is no need for an operation to implement this therapy. Being a dopamine agonist, apomorphine is not a suitable therapy for patients with a history of psychosis or compulsive obsessive behaviours. Continuous intrajejunal instillation of levodopa may be an alternative for those who do not tolerate apomorphine. The implementation of the percutaneous endoscopic jejunostomy (PEJ), however, requires an operation. The advantage is that levodopa is a monotherapy and gives the patient independence from additional Parkinson medication during the day. For younger patients, deep brain stimulation of the subthalamic nucleus is a well-investigated and approved alternative. Careful preoperative evaluation with strict adherence to inclusion and exclusion criteria is mandatory for this most invasive of therapies. According to recent data, deep brain stimulation may be recommended in earlier and moderately severe stages of the disease when fluctuations have just begun. On the other hand, limitations due to age and levodopa-resistant symptoms need to be considered. All three invasive therapies should be implemented and supervised only by specialized physicians.

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