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Parkinson's disease - Management
How might a specialist manage dyskinesias?

Peak-dose dyskinesia

  • Add amantadine:
    • The benefit may be limited to 8 months' duration.
  • Reduce the individual levodopa dose, whilst increasing the dose frequency to compensate for the risk of increased 'off' time. The total daily dosage should remain the same as before.
  • Discontinue or reduce the dose of catechol-O-methyl transferase (COMT) inhibitor or monoamine oxidase-B (MAO-B) inhibitor (at the risk of worsening the effects of wearing off).
  • Use an apomorphine continuous subcutaneous infusion, which allows reduction of levodopa dosing.
  • Perform deep brain stimulation (DBS) of the subthalamic nucleus (STN).
  • Add an atypical antipsychotic (such as clozapine or quetiapine), although adverse effects and monitoring limit their use, particularly for clozapine.

Diphasic (biphasic) dyskinesia

This type of dyskinesia can be very difficult to treat.

  • Strategies for peak-dose dyskinesia may be employed.
  • Increasing the size and frequency of the levodopa dose may be used (but this risks inducing or increasing peak-dose dyskinesia).
  • Larger, less frequent levodopa doses may be considered.

Off-state dystonia

  • Change the levodopa dosing schedule.
  • Add an oral dopamine agonist, a COMT inhibitor, or a MAO-B inhibitor.

[Horstink et al, 2006; National Collaborating Centre for Chronic Conditions, 2006; Pahwa et al, 2006; Chou, 2008]

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