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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.