Treatment Management And Cost

The discovery of the dopaminergic deficit was the major turning point in the development of rational pharmacotherapeutic approaches to PD leading to the introduction of levodopa and later dopamine agonists. With the exception of anticholinergics and amantadine, all other drugs subsequently developed (dopa-decarboxylase inhibitors, monoamine oxidase inhibitors, catechol-O-methyl transferase inhibitors) act indirectly through dopaminergic mechanisms (1,19). Functional surgery, developed many years ago as a palliative approach to the therapy of PD, has more recently become an important therapeutic option (19, 20).

There have been newer developments in the field of PD pharmacotherapy in an attempt to intervene at different levels of the biochemical machinery of the basal ganglia beyond the dopamine agonist receptor. Drugs acting at the adenosine, glutamate, adrenergic, and serotonin receptors are at present under scrutiny as potentially beneficial at different stages of the disease (21).

Figure 3.8.1 Cost distribution in Parkinson's disease

Uncompensated Care 18.8%

Figure 3.8.1 Cost distribution in Parkinson's disease

Inpatient Care 19.9%

Uncompensated Care 18.8%

Outpatient Care 7.5%

Prescription Drugs 4.4%

Initiation of therapy depends on the age and mental status of the patient and the severity of the disease. In young patients, there is evidence supporting the postponement of more potent medications such as levodopa to prevent early development of motor complications. In older patients, not only the risk of motor complications is less, but the safety profile of levodopa is better within a higher age range. Initially, patients are generally medicated with a single drug but as disease progresses multiple medications may be required (22).

In addition to the primary medications used for symptomatic treatment of the specific motor symptoms of PD, there is also a need for complementary medication to treat the diverse non-motor symptoms (constipation, urinary incontinence, sexual dysfunction, orthostatic hypotension, sleep disorders, psychiatric symptoms such as depression, psychosis and behavioural disorders, and cognitive disturbances) that affect a significant number of patients with PD in the advanced stages.

Functional surgery, both lesional or deep-brain stimulation, also plays an important role in the treatment of the complicated PD patient with drug-refractory disease, as this resource has become increasingly useful in the management of motor complications (motor fluctuations and dyskinesias) (20). Three different brain targets for surgery are presently used, depending on the characteristics of the patient.

The comprehensive management of the disease requires, in addition to medical and surgical treatment, the participation of numerous other medical disciplines and health-related professionals, including physical therapist, specialized nurse, occupational therapist, speech and deglutition disorders specialist, psychologist, psychiatrist, urologist and gastroenterologist.

It is also important to deal with the issues related to cost of the disease for the patient, family and society. Unfortunately, available information is limited, and almost restricted to Europe and North America, which makes it difficult to extrapolate it to other regions of the world. It is perhaps better to analyse it in relative terms compared with a control population than to make absolute currency estimates. In a recently published study from the United States, the annual utilization of health services and cost for the PD cohort was significantly higher than for a control population. On an annual basis, PD patients spend approximately two more days in hospital, 43 more days in long-term care institutions, and fill more than 20 more prescriptions than do the controls. The total annual cost is more than double that of the control population, even before adding indirect costs (uncompensated care, productivity loss, etc.). Prescription drugs account for roughly 5% of total costs, followed by outpatient care 7.5%, uncompensated care 19%, and inpatient care 20%, while productivity loss is by far the largest share of the total cost reaching almost 50%. Figure 3.8.1 provides a breakdown of cost distribution in Parkinson's disease according to a study by Huse et al. (23).

Cost is also relative to accessibility to health delivery and medications, which is quite variable in different regions of the world. An indirect method to estimate cost is to review health spending in absolute terms and relative to the GNP, which will show major differences from one country to another. Of course, different countries have different health priorities, and depending on life expectancy the burden of PD may differ significantly.

Inpatient Care 19.9%

Outpatient Care 7.5%

Prescription Drugs 4.4%

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