Parkinson's disease and motor fluctuations

Long-term dopaminergic therapy, whilst beneficial in treating the motor symptoms of Parkinson’s disease, can give rise to motor fluctuations, including wearing-off and the subsequent re-emergence of motor symptoms, and hyperkinetic movements or dyskinesia. These motor fluctuations can be disabling and are a common consequence of levodopa treatment in particular, especially as the disease progresses. Since treatment of motor fluctuations is difficult, low doses of dopaminergics should be used in early stages of Parkinson’s disease to target functionally relevant symptoms. And instead of levodopa, dopamine agonists, amantadine and rasagiline can be used to delay the onset of motor fluctuations. Once motor fluctuations appear, off time can be addressed with more frequent dosing of levodopa, and later adjunctive therapy with dopamine agonists, COMT-inhibitors or MAO-B inhibitors may become necessary. Reduction in levodopa should be the first step in the treatment of dyskinesia, and addition of amantadine is another useful strategy but only a temporary solution. Deep brain stimulation should only be considered when all medical options have been exhausted.