Objective: The present study aims to: i) systematically evaluate literature data on acute medical management after subthalamic nucleus (STN) deep brain stimulation (DBS)  and, ii) propose a clinical algorithm focused on the patient’s phenotypic profile.

Background: STN-DBS is an established and effective form of treatment that improves motor fluctuations, dyskinesia and quality of life in patients with Parkinson’s Disease (PD). The keys points for the success of the procedure are the medical management and the programming strategies following DBS, in both the early and the long-term follow-up. Overall, the levodopa equivalent daily dose (LEDD) is reduced by 30 to 50% one year after surgery among the trials, but it is not well established how this reduction should be performed, with little scientific evidence to aid the medical management of these patients.

Method: A systematic evaluation of literature data on acute medical management after STN DBS was performed.

Results: The major modifications in medication dosage occurred during the initial postoperative period. Initially, the aim is to withdraw sequentially anticholinergic medications, followed by COMT inhibitors, amantadine and MAO inhibitor. In patients taking high doses of dopaminergic agonists, its initial reduction is recommended in order to avoid the hyperdopaminergic syndrome, particularly hypomania. On the other hand, a rapid withdrawal of dopaminergic agonists can lead to dopaminergic agonist withdrawal syndrome, characterized by apathy, pain and autonomic features. Finally, in a subset of patients with severe dyskinesia before the surgery, an initial reduction in levodopa seems to be a more reasonable approach.

Conclusion: A slow, progressive increase of STN DBS allows a decrease in dopaminergic drug dose, resulting in improvement of dyskinesia and of impulse control disorders. Changes in dopaminergic drug treatment, whether increases or decreases, should always be made progressively to avoid overstimulation and withdrawal syndromes. Pharmacological management after DBS should be individualized according to the patients clinical characteristics and baseline medications. Hyperdopaminergic and hypodopaminergic syndromes together with severe dyskinesia are the most challenges issues, and further studies are needed to better customize the medical management following STN DBS.

References: 1. Fasano A, Daniele A, Albanese A. Treatment of motor and non-motor features of Parkinson’s disease with deep brain stimulation. Lancet Neurol. 2012;11:429-42. 2. Castrioto A, Lhommée E, Moro E. Mood and behavioural effects of subthalamic stimulation in Parkinson’s disease. Lancet Neurol 2014; 13: 287–305. 3. Hacker M et al. Subthalamic Nucleus Deep Brain Stimulation May Reduce Medication Costs in Early Stage Parkinson’s Disease. Journal of Parkinson’s Disease 6 (2016) 125–131. 4. Alexoudi A. et al. The medical treatment of patients with Parkinson’s disease receiving subthalamic neurostimulation. Parkinsonism and Related Disorders xxx (2015) 1e6. 5. Fasano A et al. Medical Management of Parkinson’s Disease after Initiation of Deep Brain Stimulation. Can J Neurol Sci. 2016; 00: 1-9. 6. Russmann H, Ghika J, Combrement P, Villemure J.G, Bogousslavsky J, Burkhard P.R, Vingerhoets F.J.G. L-Dopa-induced dyskinesia improvement after STN-DBS depends upon medication reduction. Neurol. 2004;63:153-155N. 7. Olanow C et al. Factors Predictive of the Development of Levodopa-Induced Dyskinesia and Wearing-Off in Parkinson’s Disease. 8. Ardouin C, Voon V, Worbe Y, et al. Pathological Gambling in Parkinson’s Disease Improves on Chronic Subthalamic Stimulation. Moviment Disorders 2006; 21: 1941-1946. 9. Witjas T, Baunez C, Henry JM, et al. Addiction in Parkinson’s disease: impact of subthalamic nucleus deep brain stimulation. Mov Disord 2005; 20: 1052–55. 10. Thobois S, Lhommée E, Klinger H, et al. Parkinsonian apathy responds to dopaminergic stimulation of D2/D3 receptors with piribedil. Brain 2013; 136: 1568–77. 11. Czernecki V, Schüpbach M, Yaici S, Levy R, Bardinet E, Yelnik J, et al. Apathy following subthalamic stimulation in Parkinson disease: a dopamine responsive symptom. Mov Disord 2008; 23: 964–9. 12. Marin RS, Fogel BS, Hawkins J, Duffy J, Krupp B. Apathy: a treatable syndrome. J Neuropsychiatry Clin Neurosci 1995;7:23– 30. 13. Moro E et al. Referring Parkinson’s disease patients for deep brain stimulation: a RAND/UCLA appropriateness study. 14. Moro E, Allert N, Eleopra R, Houeto JL, Phan TM, Stoevelaar H, International Study Group on Referral Criteria for DBS (2009) A decision tool to support appropriate referral for deep brain stimulation in Parkinson’s disease. J Neurol 256:83–88. 15. Thobois S, Ardouin C, Lhomme´e E, Klinger H, Lagrange C, Xie J, Fraix V, Coelho Braga MC, Hassani R, Kistner A, Juphard A, Seigneuret E, Chabardes S, Mertens P, Polo G, Reilhac A, Costes N, LeBars D, Savasta M, Tremblay L, Quesada JL, Bosson JL, Benabid AL, Broussolle E, Pollak P, Krack P (2010) Non-motor dopamine withdrawal syndrome after surgery for Parkinson’s disease: predictors and underlying mesolimbic denervation. Brain 133(Pt 4):1111–1127. 16. Lhomme´e E, Klinger H, Thobois S, Schmitt E, Ardouin C, Bichon A, Kistner A, Fraix V, Xie J, Aya Kombo M, Chabarde`s S, Seigneuret E, Benabid AL, Mertens P, Polo G, Carnicella S, Quesada JL, Bosson JL, Broussolle E, Pollak P, Krack P (2012) Subthalamic stimulation in Parkinson’s disease: restoring the balance of motivated behaviours. Brain 135(Pt 5):1463–1477. 17. Lang AE, Houeto JL, Krack P, Kubu C,Lyons KE, Moro E, Ondo W, Pahwa R, Poewe W, Troster AI, Uitti R, Voon V (2006). Deep brain stimulation: preoperative issues. Mov Disord 21(Suppl 14):S171–S196. 18. Bronstein JM et al. Deep Brain Stimulation fo Parkinson Disease – An Expert Consensus and Review of Key Issues. Arch Neurol. 2011;68(2):165-171. 19. Moro E, Lang AE. Criteria for deep-brain stimulation in Parkinson’s disease: review and analysis. Expert Rev. Neurotherapeutics 6(11) 1695-1705 (2006). 20. Sriram A, Foote KD, Oyama G, et al. Brittle dyskinesia following STN but not GPi deep brain stimulation. Tremor Other Hyperkinet Mov. 2014; 4. 21. Hamani C, Florence G, Heinsen H, et al. Nucleus Deep Brain Stimulation: Basic Concepts and Novel Perspectives. ENEURO.0140-17.2017. 22. Funkiewiez A, Ardouin C, Krack P, et al. Acute psychotropic effects of bilateral subthalamic nucleus stimulation and levodopa in Parkinson’s disease. Mov Disord 2003; 18: 524-30. 23. Frank MJ, Samanta J, Moustafa AA, Sherman SJ. Hold Your Horses: Impulsivity, Deep Brain Stimulation, and Medication in Parkinsonism. Science. 2007 Nov 23;318(5854):1309-12. 24. Munhoz RP, Cerasa A, Okun MS. Surgical treatment of dyskinesia in Parkinson’s disease. Front Neurol. 2014 Apr 29;5:65. 25. Deep-Brain Stimulation for Parkinson’s Disease Study Group X. Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson’s disease. N Engl J Med (2001) 345:956–63. 26. Kleiner-Fisman G, Herzog J, Fisman DN, Tamma F, Lyons KE, Pahwa R, et al. Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes. Mov Disord (2006) 21(Suppl 14):S290–304. 27. Vingerhoets FJG, Villemure JG, FRCSC; Temperli P, Pollo C, Pralong E, Ghika J. Subthalamic DBS replaces levodopa in Parkinson’s disease – Two-year follow-up. Neurology 2002;58:396-401. 28. Zheng Z, Yongjie Li, Jianyu Li, Yuqing Zhang, Xiaohua Zhang, Ping Zhuang. Stimulation-Induced Dyskinesia in the Early Stage after Subthalamic Deep Brain Stimulation. Stereotact Funct Neurosurg 2010;88:29–34. 29. Fasano A, Romito LM, Daniele A, et al. Motor and cognitive outcome in patients with Parkinson’s disease 8 years after subthalamic implants. Brain 2010; 133: 2664–76.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/medical-management-after-subthalamic-nucleus-deep-brain-stimulation-in-patients-with-parkinsons-disease/