RESUMO
Subthalamic nucleus deep brain stimulation (STN DBS) is an established treatment that improves motor fluctuations, dyskinesia, and tremor in Parkinson's disease (PD). After the surgery, a careful electrode programming strategy and medical management are crucial, because an imbalance between them can compromise the quality of life over time. Clinical management is not straightforward and depends on several perioperative motor and non-motor symptoms. In this study, we review the literature data on acute medical management after STN DBS in PD and propose a clinical algorithm on medical management focused on the patient's phenotypic profile at the perioperative period. Overall, across the trials, the levodopa equivalent daily dose is reduced by 30 to 50% one year after surgery. In patients taking high doses of dopaminergic drugs or with high risk of impulse control disorders, an initial reduction in dopamine agonists after STN DBS is recommended to avoid the hyperdopaminergic syndrome, particularly hypomania. On the other hand, a rapid reduction of dopaminergic agonists of more than 70% during the first months can lead to dopaminergic agonist withdrawal syndrome, characterized by apathy, pain, and autonomic features. In a subset of patients with severe dyskinesia before surgery, an initial reduction in levodopa seems to be a more reasonable approach. Finally, when the patient's phenotype before the surgery is the severe parkinsonism (wearing-off) with or without tremor, reduction of the medication after surgery can be more conservative. Individualized medical management following DBS contributes to the ultimate therapy success.
Assuntos
Doença de Parkinson , Estimulação Encefálica Profunda , Humanos , Levodopa , Fenótipo , Qualidade de Vida , Núcleo Subtalâmico , Resultado do TratamentoRESUMO
Abstract Subthalamic nucleus deep brain stimulation (STN DBS) is an established treatment that improves motor fluctuations, dyskinesia, and tremor in Parkinson's disease (PD). After the surgery, a careful electrode programming strategy and medical management are crucial, because an imbalance between them can compromise the quality of life over time. Clinical management is not straightforward and depends on several perioperative motor and non-motor symptoms. In this study, we review the literature data on acute medical management after STN DBS in PD and propose a clinical algorithm on medical management focused on the patient's phenotypic profile at the perioperative period. Overall, across the trials, the levodopa equivalent daily dose is reduced by 30 to 50% one year after surgery. In patients taking high doses of dopaminergic drugs or with high risk of impulse control disorders, an initial reduction in dopamine agonists after STN DBS is recommended to avoid the hyperdopaminergic syndrome, particularly hypomania. On the other hand, a rapid reduction of dopaminergic agonists of more than 70% during the first months can lead to dopaminergic agonist withdrawal syndrome, characterized by apathy, pain, and autonomic features. In a subset of patients with severe dyskinesia before surgery, an initial reduction in levodopa seems to be a more reasonable approach. Finally, when the patient's phenotype before the surgery is the severe parkinsonism (wearing-off) with or without tremor, reduction of the medication after surgery can be more conservative. Individualized medical management following DBS contributes to the ultimate therapy success.
Resumo A estimulação cerebral profunda do núcleo subtalâmico (ECP NST) é um tratamento estabelecido para doença de Parkinson (DP), que leva à melhora das flutuações motoras, da discinesia e do tremor. Após a cirurgia, deve haver uma estratégia cuidadosa de programação da estimulação e do manejo medicamentoso, pois um desequilíbrio entre eles pode comprometer a qualidade de vida. O gerenciamento clínico não é simples e depende de vários sintomas motores e não motores perioperatórios. Nesta revisão, discutimos os dados da literatura sobre o tratamento clínico agudo após a ECP NST na DP e propomos um algoritmo clínico baseado no perfil fenotípico do paciente no período perioperatório. Em geral, nos estudos clínicos, a dose diária equivalente de levodopa é reduzida em 30 a 50% um ano após a cirurgia. Em pacientes que recebem altas doses de medicações dopaminérgicas ou com alto risco de impulsividade, recomenda-se redução inicial do agonista dopaminérgico após a ECP NST, para evitar síndrome hiperdopaminérgica, particularmente a hipomania. Por outro lado, uma rápida redução de agonistas dopaminérgicos em mais de 70% durante os primeiros meses pode levar à síndrome de abstinência do agonista dopaminérgico, com apatia, dor e disautonomia. Em pacientes com discinesia grave antes da cirurgia, é recomendada redução inicial na dose de levodopa. Finalmente, quando o fenótipo do paciente antes da cirurgia é o parkinsonismo grave (flutuação motora) com ou sem tremor, a redução da medicação após a cirurgia deve ser mais conservadora. O tratamento médico individualizado após a ECP contribui para o sucesso final da terapia.