Zwei Non-Ergot-Dopaminagonisten - Rotigotin als erstes „Parkinson-Pflaster” und Piribedil - sind seit 2007 sowohl zur Mono- als auch zur Kombinationstherapie mit L-Dopa zugelassen. Hinzu kommt Ropinirol in einer neuen, retardierten Darreichungsform, das nur einmal täglich eingenommen werden muss. Der Einsatz des parenteralen Non-Ergot-Dopaminagonisten Apomorphin als Penject zum bedarfsorientierten Einsatz oder über eine Mikropumpe zur kontinuierlichen subkutanen Infusion bei Off-Phasen wächst und eignet sich auch für Patienten in Warteposition für die tiefe Hirnstimulation. L-Dopa gilt weiterhin als die Referenz in der Parkinsontherapie. Die COMT-Hemmer Entacapon (als Einzel- oder Kombinationspräparat mit L-Dopa/Carbidopa) und Tolcapon wirken nur über eine L-Dopa-Potenzierung und sind für Wearing-off-Phänomene hilfreich. Außerdem etabliert sich ein L-Dopa/Carbidopa-Gel zur kontinuierlichen duodenalen Infusion via perkutaner endoskopischer Gastroektomie für ausgewählte Patienten mit schweren Off-Phasen. Ferner wurde 2005 ein neuer MAO-B-Hemmer, Rasagilin, für alle Phasen des idiopathischen Parkinson-Syndroms (IPS) und 2007 der Cholinesterasehemmer Rivastigimin für die Demenz bei IPS zugelassen. Wesentliche lebensqualitätsbestimmende Symptome wie Sturzneigung, Sprech- und Schluckstörungen lassen sich trotz der vielen Medikamente und der tiefen Hirnstimulation in späten Stadien der Krankheit schlecht behandeln. Hier spielen neue, symptomorientierte aktivierende Therapien eine wesentliche Rolle, deren Konzepte wie z.B. die Stimmtherapie nach Lee Silverman und das Training von Ausgleichsschritten wissenschaftlich etabliert sind. Bei der tiefen Hirnstimulation, deren Ergebnis mit der positiven Wirkung von L-Dopa korreliert, zeichnet sich der Trend ab, eher jüngere Patienten zu operieren.
Two non-ergot dopamine agonists, rotigotine (Neupro®) the first transdermal patch in Parkinson's disease (PD), and piribedil (Clarium®) have been licensed in Germany since 2007 for mono- and levodopa combination therapy. Ropinirole 24-hour prolonged release (Requip® Monotab), another non-ergot dopamine agonist, will be introduced and allow once daily dosing of ropinirol. The non-ergot parenteral dopamine agonist apomorphine available as penject for on demand use or for continuous subcutaneous infusion in patients with off-phases has an important role in patients with in complex motor fluctuations, also for those waiting for deep brain stimulation. Levodopa is still the gold standard in PD therapy. The COMT inhibitors entacapone (Comtess® or in Stalevo® as triple combination with levodopa/carbidopa) and tolcapone (Tasmar®) work only by increasing the bioavailability of levodopa and are helpful for wearing-off phenomena. Levodopa/carbidopa as a gel (Duodopa®) for continuous dudodenal infusion via PEG represents an alternative to the apomorphine pump for seleceted patients. Furthermore, in 2005 a new MAO-B inhibitor, rasagiline (Azilect®), was licensed for all PD stages and in 2007 a cholinesterase inhibitor rivastigimin (Exelon®) for PD associated dementia. However, essential quality of life determining parkinsonian symptoms such as falls, voice and swallowing symptoms are difficult to treat despite the many new drugs and deep brain stimulation (DBS). New activating therapy concepts are emerging for medication and DBS refractory symptoms, which will be increasingly evidence based such as the Lee Silverman Voice Treatment (LSVT®) and the repetitive training of compensatory steps. In DBS of the subthalamic nucleus there is a trend to operate in earlier stages of the disease course than before as the magnitude of postoperative quality of life improvement occurs mainly in young patients.
Key words
Parkinson's disease - pharmacotherapy - activating therapy - deep brain stimulation - L-Dopa
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Korrespondenz
Prof. Dr. med. Andres Ceballos-Baumann
Neurologisches Krankenhaus München Zentrum für Parkinson und Bewegungsstörungen
Parzivalplatz 4
80804 München
eMail: andres.ceballos-baumann@nk-m.de
