Timely intervention in advanced Parkinson’s disease

Managing Parkinson’s disease is as much about timing as anything else. Along with the question of when to start oral therapy is the question of when to stop it – and possibly begin non-oral, device-assisted options.

Although cast in the form of debates, there was more consensus than conflict among speakers at the EAN 2020 Virtual congress symposium on early recognition of advanced Parkinson’s disease (PD).

Based in part on evidence that non-oral therapy benefited patients in the Gloria registry,1 Per Odin (University of Lund, Sweden) advocated intervening relatively early as disease advances, and ideally also at a relatively young age. 

The conclusions of the consensus-building NAVIGATE program2 and its Delphi Panel equivalent3 both broadly support early consideration of non-oral therapies, he continued.

Non-oral therapies offer effective options when PD is no longer controlled by oral medication


The “5-2-1” criteria

The Delphi Panel formalized the definition of inadequate control by oral therapies as fulfilling at least one of following criteria: using oral levodopa five or more times per day; having at least two hours per day with “off” symptoms; or having an hour or more each day of troublesome dyskinesias. And the web-based MANAGE-PD tool now helps identify patient who should be considered for non-oral therapy.

So, much of what we need for the timely identification of advanced PD patients is in place. But we also require clear pathways of specialist referral and the capacity for multidisciplinary working, Tove Henriksen (Copenhagen University Hospital, Denmark) pointed out.

And patients must be aware of their options, informed about what they involve, and supported – perhaps by contact with others who have already had such therapies.

Are we losing time when patients could enjoy improved quality of life and function?


Standard therapy?

Regina Katzenschlager (Danube Hospital, Vienna, Austria) argued that some form of continuous dopaminergic stimulation therapy drug could now be considered standard for patients experiencing persistent motor fluctuations. 

Zvezdan Pirtošek (University Medical Center, Ljubljana, Slovenia) agreed that it is a successful, evidence-based intervention and was inclined to endorse the views of Antonini and Jenner that neurologists should be encouraged to consider device-aided therapies earlier in the disease course and before troublesome dyskinesias develop.

But, suggested Professor Pirtošek, patients need careful selection; patients, families and carers need to be more fully informed; and devices should ideally be made simpler. Until these conditions are fulfilled, non-oral therapies are only part of the way along their journey to becoming standard therapy.


The content of this article was derived from a satellite symposium sponsored by Abbvie.

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.


1. Antonini A, et al. Neurodegen Dis Manag 2018;8:161-70  

2. Odin PD, Chaudhuri KR. Parkinsonism Relat Disord 2015;21:1133-44

3. Antonini A, et al. Curr Med Res Opin 2018;34:2063-73

4. Fox SH, et al. Mov Dis 2018;33:1248-66

5. Antonini A, Jenner P. Nat Rev Neurol 2018;14:693-694

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