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CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2020; 78(04): 230-237
DOI: 10.1590/0004-282X20190188
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Medical management after subthalamic stimulation in Parkinson’s disease: a phenotype perspective

Manejo medicamentoso após estimulação subtalâmica na doença de Parkinson: uma perspectiva fenotípica
Ana Paula BERTHOLO 
1   Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, Centro de Distúrbios do Movimento, São Paulo SP, Brazil.
,
Carina FRANÇA 
1   Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, Centro de Distúrbios do Movimento, São Paulo SP, Brazil.
,
Wilma Silva FIORINI 
2   Universidade de São Paulo, Instituto de Psiquiatria, Centro de Psicologia, São Paulo SP, Brazil.
,
Egberto Reis Barbosa
1   Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, Centro de Distúrbios do Movimento, São Paulo SP, Brazil.
,
Rubens Gisbert CURY 
1   Universidade de São Paulo, Faculdade de Medicina, Departamento de Neurologia, Centro de Distúrbios do Movimento, São Paulo SP, Brazil.
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Abstract

Subthalamic nucleus deep brain stimulation (STN DBS) is an established treatment that improves motor fluctuations, dyskinesia, and tremor in Parkinson’s disease (PD). After the surgery, a careful electrode programming strategy and medical management are crucial, because an imbalance between them can compromise the quality of life over time. Clinical management is not straightforward and depends on several perioperative motor and non-motor symptoms. In this study, we review the literature data on acute medical management after STN DBS in PD and propose a clinical algorithm on medical management focused on the patient’s phenotypic profile at the perioperative period. Overall, across the trials, the levodopa equivalent daily dose is reduced by 30 to 50% one year after surgery. In patients taking high doses of dopaminergic drugs or with high risk of impulse control disorders, an initial reduction in dopamine agonists after STN DBS is recommended to avoid the hyperdopaminergic syndrome, particularly hypomania. On the other hand, a rapid reduction of dopaminergic agonists of more than 70% during the first months can lead to dopaminergic agonist withdrawal syndrome, characterized by apathy, pain, and autonomic features. In a subset of patients with severe dyskinesia before surgery, an initial reduction in levodopa seems to be a more reasonable approach. Finally, when the patient’s phenotype before the surgery is the severe parkinsonism (wearing-off) with or without tremor, reduction of the medication after surgery can be more conservative. Individualized medical management following DBS contributes to the ultimate therapy success.

Resumo

A estimulação cerebral profunda do núcleo subtalâmico (ECP NST) é um tratamento estabelecido para doença de Parkinson (DP), que leva à melhora das flutuações motoras, da discinesia e do tremor. Após a cirurgia, deve haver uma estratégia cuidadosa de programação da estimulação e do manejo medicamentoso, pois um desequilíbrio entre eles pode comprometer a qualidade de vida. O gerenciamento clínico não é simples e depende de vários sintomas motores e não motores perioperatórios. Nesta revisão, discutimos os dados da literatura sobre o tratamento clínico agudo após a ECP NST na DP e propomos um algoritmo clínico baseado no perfil fenotípico do paciente no período perioperatório. Em geral, nos estudos clínicos, a dose diária equivalente de levodopa é reduzida em 30 a 50% um ano após a cirurgia. Em pacientes que recebem altas doses de medicações dopaminérgicas ou com alto risco de impulsividade, recomenda-se redução inicial do agonista dopaminérgico após a ECP NST, para evitar síndrome hiperdopaminérgica, particularmente a hipomania. Por outro lado, uma rápida redução de agonistas dopaminérgicos em mais de 70% durante os primeiros meses pode levar à síndrome de abstinência do agonista dopaminérgico, com apatia, dor e disautonomia. Em pacientes com discinesia grave antes da cirurgia, é recomendada redução inicial na dose de levodopa. Finalmente, quando o fenótipo do paciente antes da cirurgia é o parkinsonismo grave (flutuação motora) com ou sem tremor, a redução da medicação após a cirurgia deve ser mais conservadora. O tratamento médico individualizado após a ECP contribui para o sucesso final da terapia.

Keywords:

deep brain stimulation - medical management - Parkinson’s disease - phenotype - subthalamic nucleus

Palavras-chave:

estimulação encefálica profunda - manejo medicamentoso - doença de Parkinson - fenótipo - núcleo subtalâmico


Publication History

Received: 16 October 2019

Accepted: 06 November 2019

Article published online:
13 June 2023

© 2020. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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