Treatment of motor symptoms in advanced Parkinson's disease: a practical approach

Patients with advanced Parkinson's disease (PD) are known to develop motor complications after a few years of levodopa (l-dopa) therapy. Motor fluctuations develop with increasing severity of the disease, owing to loss of dopaminergic neurons and loss of the buffering capacity of the neurons to fluctuating dopamine levels. Dyskinesias develop as a result of pulsatile stimulation of the receptors and alterations in neuronal firing patterns. l-dopa remains the gold standard medication for the treatment of patients with advanced PD. However, once motor complications on l-dopa therapy emerge, clinicians may add on other classes of antiparkinsonian drugs such as dopamine agonists, catechol-O-methyl transferase inhibitors (COMTIs) or monoamine oxidase type B inhibitors (MAOBIs). The individualisation of the treatment seems to be the key for the best approach of advanced PD patients. The present review provides the most important current clinical data in the pharmacological treatment of motor symptoms in advanced PD and provides the clinician a simple algorithm in order to determine the best suitable treatment to advanced parkinsonian patients.