gms | German Medical Science

Objective: DBS plus medication is superior to medical treatment alone in advanced Parkinson’s Disease (PD). To quantify clinical response to stimulation patients have to be awake and in the clinical OFF-condition during surgery. Therefore medication needs to be stopped completely one day prior to surgery. However this regimen leads to severe impairment of the patients due to akinesia during surgery itself and already the night before.

Few centres therefore use Apomorphine instead of oral L-Dopa during the perioperative phase to improve patient comfort. We studied the tolerance of this regimen in our patients.

Method: Retrospectively we studied the charts of 66 consecutive DBS-patients, 31 receiving apomorphine and 35 control-patients receiving oral L-Dopa, perioperatively. Medical records were screened explicitly for typical side-effects like nausea, local skin reaction, hallucinations, impuls-control-disturbance and sedation. Parallely a retrospective questionnaire was analysed that compared perioperative patient satisfaction between apomorphine- and L-Dopa patients.

Preoperatively subcutanous apomorphine was gradually increased over 2 days until good mobility was achieved for the individual patient. All apomorphine-patients were infused continuously over 24 h without pause at night and received 10 mg domperidone tid. For intraoperative clinical testing the infusion was stopped at the beginning of surgery, it was restarted directly after testing the second side. In the control group the patients received regular-release oral L-Dopa until 6 pm the day before surgery.

Results: In total 29 apomorphine-patients, (mean age 62,2) 9 women and 20 men, could be evaluated. Total infusion-time was between 3 and 11 days, dosage ranged from 2,5 to 12 mg/h. 5 patients complained about nausea, 2 about sucutanous nodules, 2 about hallucinations and 2 about sedation. In no case apomorphine needed to be discontinued. Medication side-effects did not differ statistically between both groups. Whereas akinesia was felt "very severe" in only 5.9% of the apomorphine-patients, but in 25.0% of the control-group in the morning of the day of surgery.

Conclusions: The results show that advanced PD-patients tolerate a short-term change of their oral medication to high-dose apomorphine well directly before DBS-surgery. In terms of patient comfort it therefore appears to be a good alternative to a more than 12h cessation of oral L-Dopa preoperatively.