title: Collective physician perspectives on non-oral medication approaches for the management of clinically relevant unresolved issues in Parkinson's disease: Consensus from an international survey and discussion program.
abstract: Navigate PD was an educational program established to supplement existing guidelines and provide recommendations on the management of Parkinson's disease (PD) refractory to oral/transdermal therapies. It involved 103 experts from 13 countries overseen by an International Steering Committee (ISC) of 13 movement disorder specialists. The ISC identified 71 clinical questions important for device-aided management of PD. Fifty-six experts responded to a web-based survey, rating 15 questions as 'critically important;' these were refined to 10 questions by the ISC to be addressed through available evidence and expert opinion. Draft guidance was presented at international/national meetings and revised based on feedback. Key take-home points are: • Patients requiring levodopa >5 times daily who have severe, troublesome 'off' periods (>1-2 h/day) despite optimal oral/transdermal levodopa or non-levodopa-based therapies should be referred for specialist assessment even if disease duration is <4 years. • Cognitive decline related to non-motor fluctuations is an indication for device-aided therapies. If cognitive impairment is mild, use deep brain stimulation (DBS) with caution. For patients who have cognitive impairment or dementia, intrajejunal levodopa infusion is considered as both therapeutic and palliative in some countries. Falls are linked to cognitive decline and are likely to become more frequent with device-aided therapies. • Insufficient control of motor complications (or drug-resistant tremor in the case of DBS) are indications for device-aided therapies. Levodopa-carbidopa intestinal gel infusions or subcutaneous apomorphine pump may be considered for patients aged >70 years who have mild or moderate cognitive impairment, severe depression or other contraindications to DBS.
authors.affiliation: Department of Neurology, Lund University Hospital, 221 85 Lund, Sweden; Klinikum-Bremerhaven, D-27574 Bremerhaven, Germany. Electronic address: per.odin@med.lu.se.
authors.forename: P
authors.initials: P
authors.lastname: Odin
authors.affiliation: King's College London, and National Parkinson Foundation Centre of Excellence, Dept of Neurology, King's College Hospital, London, UK.
authors.forename: K
authors.initials: K
authors.lastname: Ray Chaudhuri
authors.affiliation: Department of Neurology, University of Kentucky College of Medicine, Kentucky Clinic L-445, 740 South Limestone Street, Lexington, KY 40536-0284, USA.
authors.forename: J T
authors.initials: JT
authors.lastname: Slevin
authors.affiliation: Department of Neurology, University Hospital of Würzburg, 97080 Würzburg, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Volkmann
authors.affiliation: Department of Neurology, Oslo University Hospital and University of Oslo, N-0424 Oslo, Norway.
authors.forename: E
authors.initials: E
authors.lastname: Dietrichs
authors.affiliation: National Center for Epidemiology and CIBERNED, ISCIII, Avenida Monforte de Lemos 5, 28029 Madrid, Spain.
authors.forename: P
authors.initials: P
authors.lastname: Martinez-Martin
authors.affiliation: Department of Neurosurgery, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany.
authors.forename: J K
authors.initials: JK
authors.lastname: Krauss
authors.affiliation: University Hospital of Bispebjerg, Bispebjerg Bakke 23, 2400 København, NV, Denmark.
authors.forename: T
authors.initials: T
authors.lastname: Henriksen
authors.affiliation: Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Sozialmedizinisches Zentrum Ost - Donauspital, 1220 Wien Langobardenstraße 122, Austria.
authors.forename: R
authors.initials: R
authors.lastname: Katzenschlager
authors.affiliation: Parkinson and Movement Disorders Unit, IRCCS Hospital San Camillo, Venice, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Antonini
authors.affiliation: Clinical Investigation Center 1436 and Department of Clinical Pharmacology, INSERM and University Hospital of Toulouse, Toulouse University, 37 alées Jules Giesde, 31000 Toulouse, France; Clinical Investigation Center 1436 and Department of Neurosciences, INSERM and University Hospital of Toulouse, Toulouse University, 37 alées Jules Giesde, 31000 Toulouse, France.
authors.forename: O
authors.initials: O
authors.lastname: Rascol
authors.affiliation: Innsbruck Medical University/University Hospital, Anichstrasse 35, A-6020 Innsbruck, Austria.
authors.forename: W
authors.initials: W
authors.lastname: Poewe
mesh_terms: D006801:Humans; D009983:Orthopedic Equipment; D010300:Parkinson Disease / Q000534:rehabilitation*; D011795:Surveys and Questionnaires
keywords: Device-aided therapies; Dyskinesias; Motor fluctuations; Non-motor symptoms; Parkinson's disease