Objective: To compare Late-stage Parkinson’s disease (LSPD) patients who completed at least one year of oral medical therapy alone after IPG depletion with those who required rescue therapy (Implantable Pulse Generator (IPG) replacement or other device-aided therapies) within the same timeframe.

Background: Deep Brain Stimulation (DBS) is a recognized treatment for motor symptoms of advanced Parkinson’s disease (PD). Its management in LSPD remains a topic of significant debate. Risks and benefits of continuing therapy must be carefully evaluated as these patients approach the need for IPG replacement surgery in clinical practice.

Method: All DBS patients with late-stage Parkinson’s disease (H&Y ≥ 4, Schwab and England scale ≤ 50) for whom IPG replacement was not recommended by the clinician and caregivers and with at least one year of follow-up were retrospectively analyzed at the Advanced Therapies Clinic for Movement Disorders, Neurology Department, Arcispedale Sant’Anna di Cona, Ferrara (2010–2021). Collected data included demographics (age, sex), clinical features (disease duration, subtype, years of DBS, MMSE, MDS-UPDRS III, LEDD, NMSS, Charlson Comorbidity Index (CCI), modified Falls Efficacy Scale (mFES), Freezing of Gait questionnaire (FOGq)), and stimulation-related parameters (IPG type, battery, settings) before depletion.

Results: Twenty-five patients were included: 15 continued with medical therapy alone after IPG depletion, while 10 required IPG replacement (6) or another advanced therapy (Levodopa-Carbidopa Intestinal Gel, 4) within the first year (27.4±25.1 days from IPG depletion). The two groups differed significantly in years of DBS (12.3 ± 3.4 vs 9.0 ± 0.2) and fall risk impact (mFES: 12.8 ± 7.9 vs 9.3 ± 3.4). A trend was observed for stimulation stability (30.7 ± 9.8 vs 22.6 ± 9.6 months since last adjustment) and MDS-UPDRS III change after depletion (ΔMDS-UPDRSIII 7.6 ± 4.0 vs 10.9 ± 4.3 from ON stimulation) [table1].

Conclusion: Patients with LSPD and DBS with a longer duration of DBS therapy, prolonged stability of stimulation parameters without modifications, and a higher impact of fall risk seem to better tolerate the discontinuation of the stimulation, continuing acceptably with medical therapy and conservative treatments alone, while patients who still experience benefit from therapy on motor symptoms tend to require ongoing device-aided therapies within three months from IPG depletion.

Table 1

References: – Fabbri M, Zibetti M, Rizzone MG, Giannini G, Borellini L, Stefani A, Bove F, Bruno A, Calandra-Buonaura G, Modugno N, Piano C, Peppe A, Ardolino G, Romagnolo A, Artusi CA, Berchialla P, Montanaro E, Cortelli P, Luigi R, Eleopra R, Minafra B, Pacchetti C, Tufo T, Cogiamanian F, Lopiano L. Should We Consider Deep Brain Stimulation Discontinuation in Late-Stage Parkinson’s Disease? Mov Disord. 2020 Aug;35(8):1379-1387. doi: 10.1002/mds.28091. Epub 2020 May 25. PMID: 32449542.

– Fabbri M, Coelho M, Abreu D, Guedes LC, Rosa MM, Costa N, Antonini A, Ferreira JJ. Do patients with late-stage Parkinson’s disease still respond to levodopa? Parkinsonism Relat Disord. 2016 May;26:10-6. doi: 10.1016/j.parkreldis.2016.02.021. Epub 2016 Feb 26. PMID: 26972527.

– Coelho M, Ferreira JJ. Late-stage Parkinson disease. Nat Rev Neurol. 2012 Aug;8(8):435-42. doi: 10.1038/nrneurol.2012.126. Epub 2012 Jul 10. PMID: 22777251.

– Grimaldi S, Eusebio A, Carron R, Regis JM, Velly L, Azulay JP, Witjas T. Deep Brain Stimulation-Withdrawal Syndrome in Parkinson’s Disease: Risk Factors and Pathophysiological Hypotheses of a Life-Threatening Emergency. Neuromodulation. 2023 Feb;26(2):424-434. doi: 10.1016/j.neurom.2022.09.008. Epub 2022 Nov 4. PMID: 36344398.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/deep-brain-stimulation-in-late-stage-parkinsons-disease-insights-from-clinical-practice/