Parkinson's disease: treatment and prognosis

Parkinson's disease is a degenerative disease of the central nervous system, the causes, symptoms and diagnosis of which you learned from the previous article. This time we will talk about the possibilities of treatment, the intricacies of the use of certain drugs and the prognosis of the disease.

Treatment

Since Parkinson's disease is characterized by a slow but steady progression, all the efforts of doctors are aimed at:

• elimination of existing symptoms or at least their reduction;
• prevention of the emergence of new symptoms and the spread of the disease from one half of the body to another, transition of the disease from one stage to another according to Hen-Yar;
• modification of the way of life (in order to ensure the maximum possible existence of a maximum period of time).

The basic principle of treating Parkinson's disease is complex, that is, simultaneous action on all possible links of the disease, and by any means. Contrary to the notion of the mandatory prescription of drugs in Parkinson's disease, at some initial stages only non-drug treatment is possible.

All known to date methods of treatment can be represented as follows:

• use of medicines;
• non-pharmacological methods of treatment (physiotherapy, physiotherapy exercises, etc.);
• social rehabilitation;
• surgical methods.

Use of medicines

The general trend in prescribing drugs for Parkinson's disease: drugs are used when the existing symptoms begin to prevent the patient from leading a normal lifestyle. T. e. not immediately at the first appearance of a sign (rigidity, tremor, etc.). The use of drugs takes into account the impact in two directions: the effect on the mechanism of the development of Parkinson's disease (pathogenetic treatment) and on individual symptoms (symptomatic). The approach to prescribing drugs takes into account the stage of the disease, the rate of progression, the duration of the disease, individual characteristics (concomitant diseases, age, profession, social and marital status, characteristics character). Selection of a specific medication is a very difficult task for a neuropathologist, which is not always solved on the first attempt.

The purpose of this area in treatment is to restore household, professional, social skills to a satisfactory level with the help of minimal doses. T. e. each specific patient is given a dosage that does not necessarily completely eliminate, for example, rigidity or tremor, but will allow him to lead a normal lifestyle with minimal difficulties. This approach is used because the gradual progression of the disease requires a constant increase in the dose of the drug, which is accompanied by an increased risk of side effects. There are situations when the maximum possible dose of the drug is prescribed, and there is practically no curative effect, so one more moment in the treatment of Parkinson's disease is its dynamism. The medicines used are reviewed over time, new combinations are formed.

The groups of drugs used to treat Parkinson's disease are currently:

• amantadines;
• monoamine oxidase type B inhibitors (MAO-B);
• dopamine receptor agonists;
• anticholinergic;
• preparations of levodopa;
• inhibitors of catechol-O-methyltransferase (COMT).

Amantadines (Midantan, Neomidantan, Amantine, Gludantan) promote the release of dopamine from the depot, increase sensitivity of receptors to dopamine, inhibit the mechanisms of its re-uptake (than support it concentration). All this restores the deficiency of dopamine in Parkinson's disease. Drugs used mainly for 100 mg 2-3 r / day. The main side effects: headache, dizziness, nausea, anxiety, visual hallucinations, swelling of the lower extremities, a sharp decrease arterial pressure in the transition from the horizontal position to the vertical, the appearance of a network of marble-cyanotic skin coloration is more often on the front surface of the thigh.

MAO-B inhibitors (Selegiline, Yumex, Segan) inhibit the disintegration of dopamine, than maintain its concentration in the brain tissue at the proper level. Take 5 mg in the morning, a maximum of 5 mg 2 times a day in the morning. Usually well tolerated. The most common side effects are: decreased appetite, nausea, constipation or diarrhea, anxiety, insomnia.

Dopamine receptor agonists (Bromocriptine, Kabergolin, Pergolide, Pramipexol, Pronoran) stimulate receptors for dopamine, as if deceiving the body, replacing dopamine. The most commonly used group is Pramipexole (Mirapex). Begin with a dose of 25 mg 3 times a day, the maximum possible dose, mg / day. Side effects of Pramipexola include nausea, hallucinations, sleep disorders, peripheral edema.

Anticholinergic drugs (Cyclodol, Parkopan, Akineton) are particularly effective against tremor. Affect the imbalance of the ratio of dopamine-acetylcholine. Admission begins with 1 mg 2 times a day, if necessary, increasing the dose to therapeutically effective. These drugs can not be abruptly abolished, since withdrawal can occur (a condition in which the symptoms of Parkinson's disease increase dramatically). For this group of drugs, there are such side effects: dry mouth, visual impairment when looking from afar to close located subjects, increased intraocular pressure, increased heart rate, difficulty urinating, constipation. Recently, these drugs are used less often.

Levodopa (L-DOPA) is a synthetic precursor of dopamine, when it enters the body, it becomes dopamine, thus eliminating its deficiency in Parkinson's disease. Preparations containing levodopa are always used in combination with carbidopa or benserazide. The last two substances interfere with the disintegration of levodopa in various organs and tissues (so to speak, on the periphery, so it all enters the brain). And this provides an opportunity to get a good effect at small dosages. At the same time carbidopa and benserazide do not penetrate into the central nervous system. Combinations of levodopa with carbidopa are Nakom, Sinemet, Levokarb, Hexal; Levodopa with benserazidom - Madopar. The half-life of the drug is 3 hours. To avoid the need to take levodopa every 3-4 hours (increasing the risk of side effects), there were Synthesized preparations with proluted release of the drug, allowing to take it 2 times a day (Sinemet CR, Madopar HBS). Side effects of levodopa: nausea, vomiting, abdominal pain, the risk of gastrointestinal bleeding, a violation of the rhythm of the heart, dilated pupils, involuntary tonic contraction of the eyelids, difficulty in breathing, increased sweating, lowering of blood pressure, psychomotor agitation, psychoses, involuntary movements in extremities.

Another drug that is used in combination with levodopa is the Comt inhibitor Entacapone (Comtan). It also extends the "period of life" of levodopa. There is a combined preparation containing simultaneously levodopa, carbidopa and entacapone - Stalevo.

Levodopa is the most effective drug for treating the symptoms of Parkinson's disease. However, they try to introduce it into the treatment spectrum as late as possible. From what is such a contradiction? Because levodopa is like a "twin" of dopamine, leads to a gradual "wear" of dopamine receptors. This is the last medicine from the whole arsenal of medicines. If from it or him there is no effect-treatment by means of preparations is useless. With long-term use of levodopa in the patient there are "medicinal dyskinesia" - involuntary movements in different parts of the body that can even interfere with the patient more than the symptoms themselves Parkinson's. There is one more feature: a gradual decrease in the effect of the dose, i.e., the need for its constant increase (usually required once every 3-4 years). T. e. in the process of treatment, the patient begins to feel that he lacks the usual dose (the phenomenon of "exhaustion of the end dose "), in the intervals between receptions of levodopa symptoms return, the syndrome develops "On-off". A person loses the ability to move towards the end of the previous dose (turns off) and, as it were, turns on again after a new dose is absorbed. But this "inclusion" does not last long, the new dose does not have the desired effect (in terms of time and quality). In the end, the patient becomes helpless. It is rather difficult to correct this feature of prolonged use of levodopa. Usually, for a while the treatment with levodopa is canceled, creating a kind of "vacation". This is done only in a hospital. But not always the drug cancellation helps. All these features of the use of levodopa and force doctors to resort to its use as late as possible (usually to 60-70 years). Clear criteria, when it is necessary to start using levodopa, is currently not available.

Most of the drugs used to treat Parkinson's disease, enhance each other's action. This phenomenon is used to achieve a clinical effect, adding a new drug when the previous one is ineffective in a small dosage. This helps to prolong the period of influence on the symptoms of the disease, and therefore, to ensure the best possible quality of life longer.

The pharmacological treatment of Parkinson's disease in the early periods (stages I-II according to Hen-Yar) differs from that in later stages.

Early treatment

Preferably, dopamine receptor agonists, MAO-B inhibitors, amantadines are used. Begin treatment with a single drug (at the choice of a doctor and patient, taking into account all individual features), with a decrease in the effect and progression of the disease gradually combining above listed groups. In young (younger than 50 years) use and anticholinesterase funds. The addition of drugs containing levodopa is necessary when motor disorders lead to a restriction of independence patient in the home (but before reaching stage III of the Hen-Yar) and are no longer eliminated by the use of other antiparkinsonian drugs.

Treatment in later stages

As the disease is steadily progressing, more and more symptoms appear in the clinical picture, the "old" ones are progressing. Usually at this point the patient is already receiving some time therapy with drugs levodopa. There is an accustoming to the usual dose, it has to be increased. For some time, joint application of dopamine receptor agonists and levodopa is possible, which allows not to increase the dose of the latter. The daily dose of levodopa is divided into smaller and more frequent methods, and long-acting forms are taken. An alternative to this may be the use of the complex drug Stalevo.

Thus, in the late stage of Parkinson's disease, it is very difficult to maintain a balance between the dose of the drug that has a curative effect and causes side effects. Against the background of long-term administration of levodopa, the patient appears "drug dyskinesia the syndrome "on-off the phenomenon of "exhaustion of the end of the dose." All these violations are very difficult to control. Mental disorders are aggravated, orthostatic hypotension appears (a sharp decrease in the arterial pressure during the transition from horizontal to vertical position), which provokes fainting and falling. Hallucinations, depression, delusions, behavior disorders at this stage require treatment by a psychiatrist. Therapeutic correction in the late stages of the disease is difficult because, reducing one manifestation, the drugs invariably provoke others. And the treatment in this situation is to find the "golden mean".

Non-drug therapies

Proper nutrition improves the condition of people with Parkinson's disease.

This group of methods of influence is applied irrespective of the stage of the disease.

Nutrition in Parkinson's disease has the following features. It is recommended to eat foods rich in fiber (vegetables, fruits, cereals, boiled legumes, black bread, oat flakes). This helps to prevent constipation, to which patients are prone. Most of the products are best used in cooked or baked form. It is necessary to reduce the consumption of animal fats, to consume a sufficient amount of liquid. In some cases, it is required to reduce the protein content in the diet (with prolonged intake of levodopa).

With Parkinson's disease, the very process of eating food presents certain difficulties (trembling and stiffness make it difficult to get into the mouth, grasp a cup or glass, etc.). Help such simple manipulations, such as attaching a plate to a table, drinking from a tube, using a spoon, the handle of which is thickened (for example, wrapped in a cloth). To facilitate swallowing, the food should be thoroughly chewed and washed down with small sips of liquid. When swallowing, it is slightly bent forward, this facilitates the passage of food through the esophagus. The intake of food must be regulated with taking medications (some antiparkinsonian drugs are taken only during meals, others - on an empty stomach or in the interval between meals).

Therapeutic exercise has a significant effect, especially in the early stages. The patient is taught to exercise to relax the muscles (which somewhat reduces rigidity), exercise to preserve balance, breathing exercises, training of facial muscles and muscles involved in the reproduction of speech, etc. In itself, exercise therapy can not slow the progression of the disease, but can delay the onset disability, does some time motor disorders are not so noticeable, not so hampering the household activity. In the initial stages of Parkinson's disease, exercise can be quite high (dancing, moving ball games, skiing, aerobics). In later stages, physical exercises should be strictly dosed: walking, swimming, simulators, etc. It should be noted and the positive psychological effect of regular physical education classes.

Among the physiotherapy methods are transcranial magnetic stimulation, radon, coniferous, hydrogen sulphide baths. Massage and acupuncture are shown. There are data on the effectiveness of such methods as phototherapy (light treatment), deprivation of sleep (interruption of sleep for a certain period).

Not the last role among non-pharmacological methods of treatment belongs to psychotherapy. Different techniques allow the patient to "take" the disease and learn to enjoy life, help not to become depressed. Psychotherapy can slow the formation of mental disorders.

Social rehabilitation

Social rehabilitation is aimed at improving the quality of life of a patient with trembling paralysis, so that the patient feels himself to be a full-fledged member of society as long as possible. This is a huge package of measures, which includes "modification of the lifestyle for security and comfort." Arrangement of housing and household (handrails, chairs with backrest and armrests, railing around the room, high enough bed, lamp near it, the lack of carpets, special devices for eating food, electric toothbrushes, a bathing chair, the replacement of buttons on things on Velcro and much more) contributes to better fitness for ordinary life, reduces the need for an outsider assistance.

Surgery

These methods are usually used, if available:

• loss of the effect of anti-Parkinsonian drugs or their poor tolerance;
• the emergence of uncontrolled adverse symptoms from therapy;
• a trembling form of the disease, initially poorly amenable to drug correction.

Operative treatment is subject to patients with a duration of the disease for more than 5 years, with Stage III according to Hen-Yar (and above), in the absence of pronounced mental and speech disorders, depression.

Methods of surgical intervention:

• stereotaxic destruction of the ventrolateral nucleus of the thalamus or subthalamic nucleus: with the help of a special device, the exact place in the brain is calculated, which must be destroyed. Through a small hole in the skull, the instrument is inserted under X-ray control, and destruction is performed (in different ways). The operation does not require general anesthesia;
• deep brain stimulation: the electrodes are implanted in the brain. They are connected to an impulse generator, which sends electrical impulses to certain structures of the brain. Pulses can be adjusted if necessary. This is the most preferred technique to date, since the structures of the brain remain intact, and there is the possibility of correction of treatment;
• pallidotomy (a stereotaxic operation to destroy the pale sphere).

Among the experimental methods of treatment should be noted intracerebral transplantation of human dopamine-containing neurons (embryonic tissue) and gene therapy. These methods are under study.

Forecast

Unfortunately, the truth for today is this: Parkinson's disease is incurable. But scientists have learned to eliminate symptoms, slow progress, and for a long time improve professional and social activities. In the absence of medical care, an average of 10 years with Parkinson's disease the patient is confined to bed.

Persons receiving medication, significantly longer retain the ability to self-service and movement. Almost 90% of such patients live more than 15 years from the moment of diagnosis without need for help, over this period they already need care. Usually, death comes from intercurrent illness (for example, pneumonia, ischemic heart disease, etc.).

Parkinson's disease is a rather severe neurological disease, but compliance with all the doctor's recommendations, as well as a multifaceted approach to treatment allow the patient to be professionally and socially for a long time in demand.

Educational program in neurology. Theme "Parkinson's disease".