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Paramedische richtlijn parkinson met beslisondersteuning

A.7 Medicamenteuze behandeling

Levodopa vormt nog steeds de ‘gouden standaard’ bij de behandeling. Dit middel is het beste in staat om de symptomen rigiditeit, bradykinesie en tremor te verlichten.
Naast levodopa worden ook dopamineagonisten voorgeschreven. Dopamineagonisten kunnen andere vervelende bijwerkingen verminderen, zoals restless legs syndrome (RLS), doorslaapproblemen en ’s ochtends vroeg optredende akinesie of dystonie. 

Ter vermindering van motorische complicaties die als gevolg van het levodopagebruik kunnen ontstaan, worden soms monoamineoxidase (MAO) B-remmers voorgeschreven.

De belangrijkste motorische complicaties van medicatiegebruik zijn:

  • Responsfluctuaties, ofwel on- en off-fasen. De periode dat de medicatie prima werkt, wordt de on-fase genoemd; de periode dat de ingenomen dosis geen of onvoldoende effect heeft, de off-fase. In de beginfase van de ziekte is het optreden van deze fasen voorspelbaar en gerelateerd aan het moment waarop de medicatie is ingenomen. 
    In die fase treedt na de on-fase, voorafgaand aan de volgende dosis, het wearing off-fenomeen op, ook volgens een voorspelbaar patroon. Na verloop van tijd is niet meer te voorspellen wanneer zich een on- of een off-fase zal voordoen.
  • Early morning dystonia. Oncontroleerbare en soms pijnlijke spierspasmen, die door patiënten ervaren worden als ‘hevige kramp’. Deze complicatie houdt verband met responsfluctuaties.
  • Dyskinesieën. Onvrijwillige, onrustige bewegingen met een grote bewegingsuitslag. Ze ontstaan vaak zodra de piekplasmaspiegel bereikt is en worden dan ook wel aangeduid als piekdosisdyskinesieën of piekdosishyperkinesieën. Ze ontstaan voornamelijk door dopamine. Bij gebruik van hoge doses dopamineagonisten zullen de dyskinesieën minder ernstig zijn.

Bij aanwezigheid van deze complicaties dient de fysiotherapeut de patiënt te adviseren om dit aan te kaarten bij de zorgcoördinator of de voorschrijvend neuroloog.

Freezing is meestal het ergst tijdens een off-fase. Door aanpassing van het levodopagebruik kan geprobeerd worden om de onfase te verlengen en zo de freezingproblematiek te verminderen. Onder invloed van de ziekteprogressie ontstaan na verloop van tijd problemen waarop levodopa weinig effect heeft. Voorbeelden daarvan zijn autonome disfunctie, houdingsinstabiliteit, vallen en dementie.

Omdat bijwerkingen van medicatie invloed kunnen hebben op de fysiotherapeutische behandeling, is kennis van medicatie aanbevolen. Een uitgebreide beschrijving van medicatie en hun bijwerkingen is opgenomen het Addendum Praktijk.

Aanwezigheid van stoornissen in functies die met de voorgeschreven medicatie minder zichtbaar zouden moeten zijn, kan duiden op gebrekkige therapietrouw. Alertheid hierop blijft geboden.

Met antiparkinsonmedicatie wordt geprobeerd om het verstoorde neurotransmitterevenwicht in de circuits van de basale ganglia te herstellen. Vaak zijn hiervoor dagelijks meerdere doses van verschillende middelen nodig. Dit is een van de redenen dat veel patiënten hun medicatie niet volgens voorschrift gebruiken.197-199

Andere redenen voor de gebrekkige therapietrouw zijn cognitieve stoornissen, angst voor bijwerkingen, slikproblemen en aantasting van de fijne motoriek.197 De fysiotherapeut kan gebrekkige therapietrouw signaleren als de aanwezigheid van stoornissen, die met de voorgeschreven medicatie minder zichtbaar zouden moeten zijn. In zulke gevallen dient de fysiotherapeut de patiënt aan te moedigen het medicatiegebruik aan te kaarten bij de parkinsonverpleegkundige of voorschrijvend neuroloog.

Bij de medicamenteuze behandeling nemen levodopa en dopamineagonisten momenteel de belangrijkste plaats in. Levodopa vormt nog steeds de ‘gouden standaard’. Dit middel is het beste in staat om de symptomen rigiditeit, bradykinesie en tremor te verlichten.200 Aangezien eiwitten de werking van levodopa verminderen, wordt vaak aanbevolen om de eiwitinname over specifieke momenten op de dag te verdelen.201,202 Ook freezing kan verminderd worden met levodopa. Freezing is meestal het ergst tijdens een off-fase. Door aanpassing van het levodopagebruik kan geprobeerd worden om de on-fase te verlengen en zo de freezingproblematiek te verminderen.203 Onder invloed van ziekteprogressie ontstaan na verloop van tijd echter ook problemen waarop levodopa weinig effect heeft. Voorbeelden daarvan zijn autonome disfunctie, houdingsinstabiliteit, vallen en dementie.

Naast levodopa worden ook dopamineagonisten voorgeschreven. Deze kunnen andere vervelende bijwerkingen verminderen, zoals restless legs syndrome (RLS), doorslaapproblemen en ’s ochtends vroeg optredende akinesie of dystonie. Een aanpak die in de afgelopen tien jaar veel is getest, is een behandeling waarbij eerst alleen een dopamineagonist wordt gebruikt en vervolgens levodopa wordt toegevoegd, zodra de dopamineagonist er niet meer in slaagt de symptoomverergering onder controle te houden. Eerder bestond de standaardaanpak eruit om al in de eerste maanden van de behandeling zowel een dopamineagonist als levodopa te gebruiken. Wat de beste aanpak is, is nog niet onderzocht. Aangenomen wordt dat dopamineagonisten minder effect hebben dan op dopaminesuppletie gerichte medicatie.

Desondanks worden dopamineagonisten vaak in de beginstadia van de ziekte voorgeschreven aan patiënten die op jongere leeftijd de ziekte van Parkinson krijgen en een grotere kans hebben op motorische complicaties. Monoamineoxidase (MAO) B-remmers worden vaak al in een vroeg stadium van de ziekte gebruikt, of naast levodopa, ter vermindering van motorische complicaties.

Een overzicht van de medicatie en de bijwerkingen daarvan is opgenomen in het Addendum Praktijk, hoofdstuk 3.

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