VROEG of LAAT… in de ziekte van Parkinson

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1 VROEG of LAAT… in de ziekte van Parkinson
Nycteumdag huisartsen Donderdag 22 april 2010 Dr. EMJ Foncke bewegingsstoornissen neuroloog Afdeling Neurologie VU medisch centrum

2 Inleiding Mythen en sagen over de medicamenteuze behandeling Op zoek naar de holy grail: de nieuwe therapieën

3 Inleiding ziekte van Parkinson
Prevalentie: / Prevalentie neemt toe met leeftijd Debuut: jaar Man>vrouw The prevalence of PD is estimated between cases per persons

4 Diagnose ziekte van Parkinson
Anamnese Klinische diagnose Beeldvorming MRI-scan hersenen DAT-SPECT Neurologisch onderzoek The diagnosis of PD is in the first place a clinical diagnosis based on the patients history in combination with a careful neurological examination with emphasis on the extrapyramidal system. Imaging is important to exclude other causes of parkinsonism and in case of doubt a DATspect may support the clinical diagnosis. But I’ll come back to this later.

5 Diagnose Parkinsonisme
rigiditeit monotone spraak bradykinesia hypomimiek micrografie rust tremor (4-6 Hz) marche à petit pas Let’s move to the diagnostic steps in PD. First of all we have to make the clinical diagnosis of parkinsonism. Parkinsonism is characterised by bradykinesia in combination with one of the three symptoms displayed here. Rigidity, resting tremor or postural instability. Examples of bradykinesia are decreased expression of the face, smaller writing, walking with short steps and decreased speech volume. posturale instabiliteit

6 Tremor video

7 Hypokinesie video

8 MYTHEN EN SAGEN over de medicamenteuze behandeling
De Angst levodopa = neurotoxisch = responsfluctuaties = verliest werkzaamheid De Feiten non dopaminerge functiestoornissen kwaliteit van leven dyskinesieën

9 De ANGST LEVODOPA=NEUROTOXISCH

10 Parkinson study group, NEJM

11 Levodopa= Responsfluctuaties
Response Threshold Dyskinesia Threshold Time (h) Vroege PD Levodopa Clinical Effect 2 4 6 Response Threshold Time (h) 4 Dyskinesia Threshold 2 Matige PD Clinical Effect Levodopa 6 Gevorderde PD Time (h) Clinical Effect Levodopa 2 4 6 Dyskinesia Threshold Response Threshold Pulsatiele dopaminerge stimulatie

12 Levodopa verliest werkzaamheid
Postsynaptische dopamine receptoren verdwijnen Ogenschijnlijke ongevoeligheid

13 De FEITEN Non dopaminerge functiestoornissen Preklinisch
Vroeg klinisch Due to the work of Braak, a german neuropathologist we know that the degeneration proces in PD starts at a lower level than the sn in the brainstem, affecting non dopaminergic structures. The so called preclinical stage of pd. The degeneration proces progresses in a rostral direction affecting the sn at the early clinical stage where at that time motor symptoms become manifest. At the late clinical stage there is also involvement of different cortical structures often leading to dementia Laat klinisch BRAAK stadia

14 Kwaliteit van leven

15 Dyskinesieën

16 De PRAKTIJK Levodopa Dopamine-agonist MAO-B remmer

17 De HOLY GRAIL en nieuwe therapieën
Diepe hersenstimulatie Duodopa pompbehandeling

18 Rationale: Continue dopaminerge stimulatie

19 Diepe hersenstimulatie
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20 Diepe hersenstimulatie
Wie? Wanneer? Waar?

21 Duodopa pompbehandeling

22 VROEG of LAAT OP MAAT