Parkinson’s: Pump therapies

What are pump therapies?

Parkinson’s patients often suffer from this so-called “pulsatile” treatment during the course of the disease, which manifests itself with alternating under- and over-movements at low and high concentrations in the brain. In addition, many Parkinson’s patients do not have reliable gastric emptying, which leads to unreliable absorption of the medication and further exacerbates the problems.

Pump therapies, which are available in liquid or gel form, therefore deliver medication continuously into the bloodstream and thus into the brain via various routes: either via the small intestine (Duodopa®) or via the skin (apomorphine).

For which Parkinson's patients is pump therapy recommended?

Parkinson’s patients with

• motor fluctuations under classical drug therapy (poorly controlled under- and over-movements)
• Contraindications against deep brain stimulation
• Intact social environment (operation and care of the pump must be guaranteed)

Preliminary and follow-up examinations

In order to select patients for treatment in the best possible way and for rigorous quality control, various examinations are required before the operation and 6 months afterwards. The aim is to ensure that treated patients have the best possible chances of achieving the best possible result with as few side effects and complications as possible.

The L-dopa test examines whether Parkinson’s symptoms improve significantly with high-dose levodopa medication. The result of this test allows an assessment of the potential benefit of ultrasound therapy and thus plays an important role in the decision about the therapy. The alcohol test examines the extent to which a tremor changes after consuming alcohol.

** There have been isolated reports of polyneuropathy occurring during Duodopa therapy, i.e. damage to the finest nerves that supply the feet and lower legs in particular. This can lead to gait instability and is investigated by means of an electroneuromyographic examination (polyneuropathy screening).

The examination results are discussed in detail with patients and their loved ones before treatment and information is provided about the advantages and disadvantages, opportunities and risks. Only then is a final decision made on whether to carry out a test phase over several days in the hospital.

Test phase

During the test phase, patients and their relatives can decide together with the treating physicians whether pump therapy should be definitively established. With the apomorphine pump with subcutaneous (under the skin) injections, this is easy, with the Duodopa® pump a test phase is carried out first.

This means that the medication is not administered directly via a tube through the abdominal skin, but first via a naso-gastrointestinal tube. During this test phase, a decision can be made as to whether continuous administration of medication can achieve a decisive reduction in under- and over-movement for the patient. Only in the latter case is a pump insert definitely pursued.

Procedure

Before the treatment:

Change of medication as determined by the treating neurologist.

Admission to hospital:

1 day before the start of the test phase.

Test phase:

Duration approx. 2-6 days

Treatment:

Duodopa®: PEJ (percutaneous endoscopic jejunostomy), i.e. the gastroenterologist visually guides a thin tube through the abdominal wall directly into the small intestine.

Dose titration: After the pump system, the dose is slowly titrated to the optimum treatment. This initially takes place in hospital and then either in inpatient rehabilitation or directly at home. Curarex employees look after patients in this important phase on a daily basis, both in hospital and at home.

Possible risks and side effects of pump therapies

As with oral and transdermal dopaminergic medication, Duodopa therapy can lead to psychiatric side effects such as hallucinations or hyperactivity/dyskinesia, which can be remedied by adjusting the flow rates of Duodopa therapy and possibly using additional medication. It can also happen that the gastric or jejunal tube becomes blocked if not properly cared for or dislocated if handled incorrectly. The Curarex AG team will be happy to assist you at any time during a home visit or the gastroenterology colleagues at the USZ. A further complication is local hypergranulation if the tube and the tube system are not cared for properly, which is also treated by Curarex AG or gastroenterologists.

At the beginning of apomorphine therapy, there is a possibility of malaise, increased tiredness and low blood pressure. For this reason, patients are also given antiemetic treatment in preparation. Nodules may form locally at the puncture sites of the subcutaneous fatty tissue, but this can be successfully countered after removal of the needle with appropriate skin care and local massage with a hedgehog ball or adjustment of the puncture material.

In addition to the treatment team at the USZ, an external team of specialized nursing staff from Curarex AG, Spirig Health Care or LicherMT will always be at your side when dealing with both pump systems. They are always available for you and can also make home visits.