- Clinical update
We were delighted that so many delegates stayed after the AGM for the final session of the Autumn meeting. One explanation could be that delegates were so concerned that this would be the last London meeting for the foreseeable future, that they wished to eke out the last remaining seconds of Hammersmith’s Novotel air. A more likely explanation is the quality of the three presentations, and the importance of Parkinson’s disease to everyday practice. Indeed, as founders of the special interest group that has now become a BGS Section, Jerry Playfer and myself reflected on the extent to which, in the UK, the management of this disease has become almost the sole province of the geriatrician. |
Dr Doug MacMahon |
The first of two Scottish geriatricians, Graeme Macphee, started the session with some very clear reminders of the need to consider the differential diagnosis, backed up with some splendid video clips of Cortico-basal degeneration and progressive supra-nuclear palsy. The value of good clinical assessment remains paramount, but can now be backed up with DaTSCAN-SPECT diagnostic imaging which, although unable to discriminate between Parkinson’s disease, Multiple System Atrophy and Progressive Supranuclear Palsy, can be useful in the differentiation of Parkinson’s disease from essential tremor.
Once the diagnosis is established, what treatment to select? David Stewart reflected on the available drugs, and stressed the importance of biological age in the selection of appropriate medication. There has certainly been a trend towards consideration of early agonist treatment for biologically younger patients, stimulated by the recent trials of both ropinirole and pramipexole. David highlighted the need to consider the cognitive state and co-morbidities of patients, and the higher risk of provoking somnolence and hallucinations for the reduction in motor fluctuations gained with this approach. Levodopa remains ‘the gold standard,’ but can now be enhanced with mono-amine oxidase inhibitors (selegiline and others in trials) or the COMT inhibitor – entacapone, which comes into its own once wearing-off develops.
Finally, Alan Whone from the Hammersmith Hospital, showed some of the magnificent, beautifully sophisticated PET scan images that can not only demonstrate the degeneration of the basal ganglia, so typical of this disease, but also the dynamic changes that occur over time. One can’t help reflecting that now we have the imaging techniques, all we are waiting for is a truly neuroprotective strategy, or even better, a neurorescue treatment. The pilot study of Glial-derived nerve growth factor (GDNF) infused into the putamen shows what could be achieved surgically, and now trials have commenced with transfected viral treatments. To conclude on a slightly skeptical note, we may have the technology, but can we afford to apply it?
Doug
MacMahon
PD Academy