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| A. Most relevant motor and non-motor symptoms that may lead to suspicion of inadequately controlled Parkinson’s disease (ranked by level of importance) [58] |
| Motor | Non-motor |
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(1) troublesome level of motor fluctuations
(2) two hours of the day with “off” symptoms
(3) At least 1
hour of the day with troublesome dyskinesia
(4) Presence of motor complications
(5) daily multiple oral levodopa doses) | (1a) Troublesome hallucinations/psychosis
(1b) Non-motor symptom fluctuations
(2a) Impulse control disorder
(2b) Troublesome level of nighttime sleep disturbances
(3a) Troublesome level of depression
(3b) Troublesome level of daytime sleepiness |
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| B. Pragmatic approach: questions for the patient | If answer is NO: potential problem | Potential solutions |
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| Are your symptoms sufficiently controlled? | Insufficient effect–the patient might be underdosed | (i) Increase dose of dopamine agonist
(ii) Increase individual levodopa doses |
| When you wake up in the morning, is your mobility acceptable? If not, how long does it take for your medication to start working? | Troublesome morning “off” time | (i) Prescribe morning levodopa for immediately after waking up
(ii) Increase dopamine agonist dose (use more in the evening)
(iii) If morning levodopa dose is less effective compared to other doses–increase this individual dose |
| When your medication starts working, does the effect last until the next dose? If not, how long do you experience symptoms? | Wearing off (motor or non-motor symptoms) | (i) Increase dopamine agonist dose
(ii) Prescribe more frequent doses of levodopa
(iii) Add a COMT inhibitor (e.g. entacapone, tolcapone) [59, 60]
(iv) Add an MAO-B inhibitor (e.g. selegiline, rasagiline [59, 60] |
| Does the effect of some of your doses take long to start or do you completely fail to experience its effects? | Delayed “on”
Failed “on” | (i) Indicate the use of levodopa always at least 30–45 minutes before or after meals (not with food)
(ii) Prescribe prokinetics (e.g. domperidone)
(iii) Exclude Helicobacter pylori and/or SIBO syndrome |
| Do you have excessive involuntary movements when your medication is working? | Dyskinesia | (i) Prescribe levodopa in lower doses and more frequently
(ii) Add amantadine [61] |
| Is your mobility during the night acceptable? | Troublesome nighttime “off” | (i) Prescribe immediate-release levodopa for nighttime wake-ups
(ii) Increase dopamine agonist (to use more in the evening) |
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