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Table 1 Treatment cascade of current dopaminergic substitution tools with respect to the concept of continuous dopaminergic stimulation

From: Drug therapy in patients with Parkinson’s disease

Drug Step Mode of action within the dopaminergic system Tolerability Main clinical relevant side effects Efficacy
MAO-B-I I stabilize dopamine levels in the striatal synaptic cleft by inhibition of dopamine metabolism +++ risk for rise of raised blood pressure and increase of liver enzymes, contraindication for simultaneous fluoxetine and fluvoxamine use, precaution with application of SSRI in general +
NMDA-A I indirect dopaminergic modulation, reduce motor complications (?) + oedema, insomnia, hallucinations +
DA II stimulate directly postsynaptic striatal receptors linked to motor symptom control + Orthostatic syndrome, oedema, nausea, slow titriation necessary ++
LD/DDI/COMT-I III precursor of dopamine, DDI and COMT-I reduce LD metabolism +++ orthostatic syndrome, homocysteine elevation (LD/DDI alone), motor complications, diarrhea (COMT-I) +++
infusion systems (apomorphine, LD) IV See DA, respectively LD line + Subcutaneous local inflammatory reactions +++
DBS V electric stimulation of the subthalamic nuclei or globus pallidus + Social adjustment problems, depression, cognitive dysfunction. +++
  1. DBS = deep brain stimulation, MAO-B-I = MAO-B-Inhibitors, NMDA-A = NMDA-antagonist, DA = dopamine agonist, LD = levodopa, DDI = decarboxylase inhibitor, COMT-I = inhibitor of catechol-O-methyltransferase, judgement on tolerability and efficacy are based on the personal experience of the author.