Tratamento da doença de Parkinson

Cardoso, Francisco

doi:10.1590/S0004-282X1995000100001

Resumos

Doença de Parkinson (DP) é a causa mais freqüente de parkinsonismo em nosso meio, responsável por 58% dos casos. Devem-se excluir outras causas, como uso de drogas antidopaminérgicas (20% dos casos). Levodopa é o agente mais importante para o tratamento de DP. Há controvérsia sobre quando se introduzir esta droga mas deve-se reservá-la para quando surgir substancial comprometimento funcional. Drogas acessórias são anticolinérgicos, úteis para o tremor; amantadina, para bradicinesia e rigidez; e agonistas dopaminérgicos que ajudam no manuseio de complicações da levodopa. A selegelina tem discreta ação sintomática e possível ação neuroprotetora. O tratamento de DP pode ser complicado por falha primária, falha secundária e problemas do uso da levodopa. A falha primária pode ser causada por uso de agentes antidopaminérgicos, presença de tremor de repouso severo ou erro diagnóstico. A causa mais comum de falha secundária é progressão da DP. As principais complicações do uso da levodopa são flutuações e discinesias. Outros problemas comuns são disautonomia, depressão, psicose e demência. Fenomenologia e manuseio destas complicações são discutidos. Perspectivas futuras incluem cirurgias para reversão de patologia.

parkinsonismo; doença de Parkinson; levodopa; discinesia; flutuação

Parkinson's disease (PD) accounts for 58% of patients with Parkinsonism. The second most common cause is drug-induced Parkinsonism, diagnosed in 20% of patients. Levodopa remains as the mainstay of PD treatment. Although there is controversy regarding the timing for beginning levodopa, it should be used when the patient develops significant disability. Other drugs that may be used are anticholinergic agents, useful for tremor; amantadine, for rigidity and bradykinesia; dopamine agonists, for the management of levedopa complications; and selegeline which may be a neuroprotector agent. Problems in the management of PD include primary failure, secondary failure and levodopa complications. Antidopaminergic drugs, severe rest tremor and diagnosis error may lead to primary failure. Progression of PD is the most common explanation for secondary failure.The most important levodopa therapy complications are dyskinesias and fluctuations. Other common problems are dysautonomia, depression, psychosis and dementia. The author discusses the phenomenology and management of these complications. Future perspectives include brain repair sugeries.

parkinsonism; Parkinson's disease; levodopa; dyskinesia; fluctuation

Tratamento da doença de Parkinson

Treatment of Parkinson's disease

Francisco Cardoso

Professor Assistente, Clínica de Distúrbios do Movimento (CDM), Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG)

RESUMO

Doença de Parkinson (DP) é a causa mais freqüente de parkinsonismo em nosso meio, responsável por 58% dos casos. Devem-se excluir outras causas, como uso de drogas antidopaminérgicas (20% dos casos). Levodopa é o agente mais importante para o tratamento de DP. Há controvérsia sobre quando se introduzir esta droga mas deve-se reservá-la para quando surgir substancial comprometimento funcional. Drogas acessórias são anticolinérgicos, úteis para o tremor; amantadina, para bradicinesia e rigidez; e agonistas dopaminérgicos que ajudam no manuseio de complicações da levodopa. A selegelina tem discreta ação sintomática e possível ação neuroprotetora. O tratamento de DP pode ser complicado por falha primária, falha secundária e problemas do uso da levodopa. A falha primária pode ser causada por uso de agentes antidopaminérgicos, presença de tremor de repouso severo ou erro diagnóstico. A causa mais comum de falha secundária é progressão da DP. As principais complicações do uso da levodopa são flutuações e discinesias. Outros problemas comuns são disautonomia, depressão, psicose e demência. Fenomenologia e manuseio destas complicações são discutidos. Perspectivas futuras incluem cirurgias para reversão de patologia.

Palavras-chave: parkinsonismo, doença de Parkinson, levodopa, discinesia, flutuação.

SUMMARY

Parkinson's disease (PD) accounts for 58% of patients with Parkinsonism. The second most common cause is drug-induced Parkinsonism, diagnosed in 20% of patients. Levodopa remains as the mainstay of PD treatment. Although there is controversy regarding the timing for beginning levodopa, it should be used when the patient develops significant disability. Other drugs that may be used are anticholinergic agents, useful for tremor; amantadine, for rigidity and bradykinesia; dopamine agonists, for the management of levedopa complications; and selegeline which may be a neuroprotector agent. Problems in the management of PD include primary failure, secondary failure and levodopa complications. Antidopaminergic drugs, severe rest tremor and diagnosis error may lead to primary failure. Progression of PD is the most common explanation for secondary failure.The most important levodopa therapy complications are dyskinesias and fluctuations. Other common problems are dysautonomia, depression, psychosis and dementia. The author discusses the phenomenology and management of these complications. Future perspectives include brain repair sugeries.

Key-words: parkinsonism, Parkinson's disease, levodopa, dyskinesia, fluctuation.

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Aceite: 18-agosto-1994.

Professor Assistente, Clínica de Distúrbios do Movimento (CDM), Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG).

1. Baldessarini RJ, Frankenburg FR.Clozapine: a novel antipsychotic agent. N Engl J Med 1991, 324: 746-754.
2. Benabid AL, Pollak P, Gervason C, Hoffman D, Gao DM, Hommel M, Perret JE, de Rougemont J. Long-term suppression of tremor by chronic stimulation of the ventral intermediate thalamic nucleus. Lancet 1991, 337: 403-406.
3. Boyce S, Clarke CE, Luquin R, Peggs D, Robertson RG, Mitchell IJ, Sambrook MA, Crossman AR. Induction of chorea and dystonia in parkinsonian primates. Mov Disord 1990, S: 3-7.
4. Cardoso F, Jankovic J. Basal ganglia and movement disorders. In Rolak L (ed). Neurology secrets. Philadelphia: Hanley & Belfus, 1993, pl27-162.
5. Cardoso F, Jankovic J. Progressive supranuclear palsy. In Calne DB (ed). Neurodegenerative diseases. Philadelphia: Saunders, 1993, p769-786.
6. Cardoso F, Jankovic J. Clinical use of botulinum neurotoxins. In Montecuco C (ed). Clostridial neurotoxins. London: Springer-Verlag, 1994. (Curr Top Microbiol Immunol) (no prelo).
7. Cedarbaum JM, Gandy SE, McDowell FH. "Early" initiation of levodopa treatment does not promote the development of motor response fluctuations, dyskinesias, or dementia in Parkinson's disease. Neurology 1991, 41: 622-629.
8. Chase TN, Mouradian MM, Engber TM. Motor response complications and the function of striatal efferent systems. Neurology 1993, 43(Suppl 6): 23-27.
9. Cummings JL. Depression and Parkinson's disease: a review. Am J Psychiatry 1992, 149: 443-454.
10. DeJong GT, Meerwaldt JD, Schmitz PIM. Factors that influence the occurence of response variations in Parkinson's disease. Ann Neurol 1987, 22: 4-7.
11. Fahn S. Fetal tissue transplants in Parkinson's disease. N Engl J Med 1992, 327: 1589-1590.
12. Fitzgerald P, Jankovic J. Nondopaminergic therapy in Parkinson's disease. In Koller WC, Paulson G (eds). Therapy of Parkinson's disease. New York: Marcel Dekker, 1990, p369-397.
13. Giladi N, McMahon D, Przedborski S et al. Motor blocks in Parkinson's disease. Neurology 1992, 42: 333-339.
14. Hughes AJ, Daniel SE, Kilford L, Lees AJ. Diagnosis of idiopathic Parkinson's disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psichiatry 1992, 55: 181-184.
15. Hughes AJ, Daniel SE, Blankson S, Lees AJ. A clinicopathologic study of 100 cases of Parkinson's disease. Arch Neurol 1993, 50: 140-148.
16. Huttner WB. Snappy exocytotoxins. Nature 1993, 365: 104-105.
17. Jankovic J, Brin MF. Therapeutics use of botulinum toxin. N Engl J Med 1991,324:1186-1194.
18. Jankovic J, Cardoso F, Grossman R. Thalamotomy for tremors. Neurology (no prelo).
19. Jankovic J, Marsden CD. Therapeutic strategies in Parkinson's disease. In Jankovic J, Tolosa E (eds). Parkinson's disease and movement disorders, Ed 2. Baltimore: William & Wilkins, 1993, pll5-144.
20. Marsden CD. Parkinson's disease. Lancet 1990, 1:948-952.
21. Mayeux R, Stern Y, Rosenstein R, Marden K, Hauser A, Cote L, Fahn S. The prevalence of dementia in idiopathic Parkinson's disease. Arch Neurol 1988, 45: 260-262.
22. Parkes JD. Domperidone and Parkinson's disease. Clin Neuropharmacol 1986, 9: 517-532.
23. Parkinson Study Group. Effect of deprenyl on the progression of disability in early Parkinson's disease. N Engl J Med 1989, 321: 1364-1371.
24. Parkinson Study Group. Effects of tocopherol and deprenyl on the progression of disability in early Parkinson's disease. N Engl J Med 1993, 328: 176-183.
25. Poewe W. L-dopa in Parkinson's disease: mechanisms of action and pathophysiology of late failure. In Jankovic J, Tolosa E (eds). Parkinson's disease and movement disorders. Ed 2. Baltimore: William & Wilkins, 1993, p103-113.
26. Rajput AH, Rozdilsky B, Rajput A. Accuracy of clinical diagnosis in parkinsonism: a prospective study. Can J Neurol Sci 1991, 18: 275-278.
27. Rinne UK. Early combination of bromocriptine and levodopa in the treatment of Parkinson's disease: a 5-year follow-up. Neurology 1987,37:826-828.
28. Rinne UK. Early dopamine agonist therapy in Parkinson's disease. Mov Disord 1989, 4: 586-S94.
29. Saint-Cyr JA, Taylor AE, Lang AE. Neuropsychological and psychiatric side effects in the treatment of Parkinson's disease. Neurology 1993, 43(suppl 6): 47-52.
30. Stacy M, Cardoso F, Jankovic J. Tardive stereotypy and other movement disorders in tardive dyskinesias. Neurology 1993, 43: 937-941.
31. Tetrud JW, Langston JW. The effect of deprenyl (selegeline) on the natural history of Parkinson's disease. Science 1989, 245: 519-522.
32. Uitti RJ, Ahlskog JE, Maraganore DM, Muenter MD, Atkinson EJ, Cha RH, O' Brien PC. Levodopa therapy and survival in idiopathic Parkinson's disease: Olmsted County project. Neurology 1993, 43: 1918-1926.
33. Weiner WJ, Factor SA, Sanchez-Ramos JR, Singer C, Sheldon C, Cornelius C, Ingenito A. Early combination therapy (bromocriptine and levodopa) does not prevent motor fluctuations in Parkinson's disease. Neurology 1993, 43: 21-27.
34. Wilson JA, Smith RG. The prevalence and aetiology of long-term 1-dopa side-effects in elderly parkinsonian patients. Ageing 1989, 18: 11-16.

Datas de Publicação

Publicação nesta coleção
19 Jan 2011
Data do Fascículo
Mar 1995

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Baldessarini RJ, Frankenburg FR.Clozapine: a novel antipsychotic agent. N Engl J Med 1991, 324: 746-754.

[2] 2. Benabid AL, Pollak P, Gervason C, Hoffman D, Gao DM, Hommel M, Perret JE, de Rougemont J. Long-term suppression of tremor by chronic stimulation of the ventral intermediate thalamic nucleus. Lancet 1991, 337: 403-406.

[3] 3. Boyce S, Clarke CE, Luquin R, Peggs D, Robertson RG, Mitchell IJ, Sambrook MA, Crossman AR. Induction of chorea and dystonia in parkinsonian primates. Mov Disord 1990, S: 3-7.

[4] 4. Cardoso F, Jankovic J. Basal ganglia and movement disorders. In Rolak L (ed). Neurology secrets. Philadelphia: Hanley & Belfus, 1993, pl27-162.

[5] 5. Cardoso F, Jankovic J. Progressive supranuclear palsy. In Calne DB (ed). Neurodegenerative diseases. Philadelphia: Saunders, 1993, p769-786.

[6] 6. Cardoso F, Jankovic J. Clinical use of botulinum neurotoxins. In Montecuco C (ed). Clostridial neurotoxins. London: Springer-Verlag, 1994. (Curr Top Microbiol Immunol) (no prelo).

[7] 7. Cedarbaum JM, Gandy SE, McDowell FH. "Early" initiation of levodopa treatment does not promote the development of motor response fluctuations, dyskinesias, or dementia in Parkinson's disease. Neurology 1991, 41: 622-629.

[8] 8. Chase TN, Mouradian MM, Engber TM. Motor response complications and the function of striatal efferent systems. Neurology 1993, 43(Suppl 6): 23-27.

[9] 9. Cummings JL. Depression and Parkinson's disease: a review. Am J Psychiatry 1992, 149: 443-454.

[10] 10. DeJong GT, Meerwaldt JD, Schmitz PIM. Factors that influence the occurence of response variations in Parkinson's disease. Ann Neurol 1987, 22: 4-7.

[11] 11. Fahn S. Fetal tissue transplants in Parkinson's disease. N Engl J Med 1992, 327: 1589-1590.

[12] 12. Fitzgerald P, Jankovic J. Nondopaminergic therapy in Parkinson's disease. In Koller WC, Paulson G (eds). Therapy of Parkinson's disease. New York: Marcel Dekker, 1990, p369-397.

[13] 13. Giladi N, McMahon D, Przedborski S et al. Motor blocks in Parkinson's disease. Neurology 1992, 42: 333-339.

[14] 14. Hughes AJ, Daniel SE, Kilford L, Lees AJ. Diagnosis of idiopathic Parkinson's disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psichiatry 1992, 55: 181-184.

[15] 15. Hughes AJ, Daniel SE, Blankson S, Lees AJ. A clinicopathologic study of 100 cases of Parkinson's disease. Arch Neurol 1993, 50: 140-148.

[16] 16. Huttner WB. Snappy exocytotoxins. Nature 1993, 365: 104-105.

[17] 17. Jankovic J, Brin MF. Therapeutics use of botulinum toxin. N Engl J Med 1991,324:1186-1194.

[18] 18. Jankovic J, Cardoso F, Grossman R. Thalamotomy for tremors. Neurology (no prelo).

[19] 19. Jankovic J, Marsden CD. Therapeutic strategies in Parkinson's disease. In Jankovic J, Tolosa E (eds). Parkinson's disease and movement disorders, Ed 2. Baltimore: William & Wilkins, 1993, pll5-144.

[20] 20. Marsden CD. Parkinson's disease. Lancet 1990, 1:948-952.

[21] 21. Mayeux R, Stern Y, Rosenstein R, Marden K, Hauser A, Cote L, Fahn S. The prevalence of dementia in idiopathic Parkinson's disease. Arch Neurol 1988, 45: 260-262.

[22] 22. Parkes JD. Domperidone and Parkinson's disease. Clin Neuropharmacol 1986, 9: 517-532.

[23] 23. Parkinson Study Group. Effect of deprenyl on the progression of disability in early Parkinson's disease. N Engl J Med 1989, 321: 1364-1371.

[24] 24. Parkinson Study Group. Effects of tocopherol and deprenyl on the progression of disability in early Parkinson's disease. N Engl J Med 1993, 328: 176-183.

[25] 25. Poewe W. L-dopa in Parkinson's disease: mechanisms of action and pathophysiology of late failure. In Jankovic J, Tolosa E (eds). Parkinson's disease and movement disorders. Ed 2. Baltimore: William & Wilkins, 1993, p103-113.

[26] 26. Rajput AH, Rozdilsky B, Rajput A. Accuracy of clinical diagnosis in parkinsonism: a prospective study. Can J Neurol Sci 1991, 18: 275-278.

[27] 27. Rinne UK. Early combination of bromocriptine and levodopa in the treatment of Parkinson's disease: a 5-year follow-up. Neurology 1987,37:826-828.

[28] 28. Rinne UK. Early dopamine agonist therapy in Parkinson's disease. Mov Disord 1989, 4: 586-S94.

[29] 29. Saint-Cyr JA, Taylor AE, Lang AE. Neuropsychological and psychiatric side effects in the treatment of Parkinson's disease. Neurology 1993, 43(suppl 6): 47-52.

[30] 30. Stacy M, Cardoso F, Jankovic J. Tardive stereotypy and other movement disorders in tardive dyskinesias. Neurology 1993, 43: 937-941.

[31] 31. Tetrud JW, Langston JW. The effect of deprenyl (selegeline) on the natural history of Parkinson's disease. Science 1989, 245: 519-522.

[32] 32. Uitti RJ, Ahlskog JE, Maraganore DM, Muenter MD, Atkinson EJ, Cha RH, O' Brien PC. Levodopa therapy and survival in idiopathic Parkinson's disease: Olmsted County project. Neurology 1993, 43: 1918-1926.

[33] 33. Weiner WJ, Factor SA, Sanchez-Ramos JR, Singer C, Sheldon C, Cornelius C, Ingenito A. Early combination therapy (bromocriptine and levodopa) does not prevent motor fluctuations in Parkinson's disease. Neurology 1993, 43: 21-27.

[34] 34. Wilson JA, Smith RG. The prevalence and aetiology of long-term 1-dopa side-effects in elderly parkinsonian patients. Ageing 1989, 18: 11-16.

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Tratamento da doença de Parkinson

Treatment of Parkinson's disease

Resumos

Datas de Publicação