How to adjust medications following deep brain stimulation surgery

-Our philosophy at the the University of Florida Center for Movement Disorders and Neurorestoration has been a "do no harm" philosophy when managing our pre- and post-surgical DBS patients.  

-Each potential subject receives a pre-operative evaluation by neurology (on-off levodopa testing if Parkinson's disease), neurosurgery,  neuropsychology, psychiatry, physical therapy, occupational therapy, speech therapy, and a swallowing aspiration study.  The results of these in person evaluations are discussed at an interdisciplinary DBS board meeting.  The DBS board determines a risk-benefit and expectation profile for each patient, and this information is communicated directly back to the patients and families.  

-Medications, and particularly Parkinson's disease medications are optimized prior to any surgical intervention.  Impulse control disorders and dopamine dysregulation syndrome are diagnosed and stabilized prior to any surgical intervention.  In most cases our team performs unilateral DBS on a target selected by the DBS board.  This target selection is based on a tailored approach to symptoms and an individualized risk/benefit ratio.  

-Following stabilization of medications and also stimulation settings, we consider the risk/benefit ratio of a second contralateral DBS device if an appropriate clinical indication can be identified.  Recent data has revealed that over 1/3 of Parkinson's disease patients may not require a second DBS (Taba 2011, NIH COMPARE study 2009) , and we advocate a "do no harm" strategy, though patients with high UPDRS scores, severe bilateral dyskinesia(s), and less symptom asymmetry may be more likely to require a second DBS device.  It should always be kept in mind that a second DBS device has the added risks of infection, hemorrhage, voice, balance, and cognitive adverse events.

-We do not routinely wean medications pre-operatively.  

-Post-operatively, we advocate a non-aggressive medication reduction strategy.  The recent reports of apathy, mood and withdrawal symptoms from rapid and aggressive medication reduction (Lhommée 2012) support the notion that best management is achieved by carefully and slowly optimizing medications and stimulation for individual patients.  Additionally, worsening of gait, balance and other features have been associated with over-aggressive medication reduction.  

-We educate patients that the goal of the surgery should not be medication reduction, but rather the goal of DBS should be focused on symptom reduction without precipitation or emergence  of any motor or non-motor symptoms.  Also, critical to post-operative DBS management, is to monitor for the de-novo appearance of impulse control disorders or dopamine dysregulation syndrome (Moum, 2012).  

-Our non-aggressive medication reduction strategy does however, attempt to ease the burden of medications for many patients.  In most cases amantadine, COMT inhibitors, and MAO-B inhibitors can be slowly weaned off (over a few weeks).  Medication intervals from dopaminergics can sometimes be lengthened, and in some cases doses of sinemet and dopamine agonists can be reduced.  In cases where a dopaminergic(s) is eliminated, we monitor closely for the emergence of apathy, mood, motor, and withdrawal symptoms.  

-There is frequently more medication reduction that can be achieved  in bilateral cases, and in STN DBS cases.  In cases where stimulation induced dyskinesia emerges, there may be a clinical need to more quickly reduce dopaminergic dosages.

-We educate patients that once the programming is optimized, the long-term management should be dominated by manipulation of pharmacotherapy, and the use of interdisciplinary and rehabilitation services.  

-In conclusion our non-aggressive approach to medication reduction post-DBS is a "do no harm" strategy that maximizes potential benefits and minimizes side effects.  When medication reduction is pursued, it is done slowly and is always carefully monitored.  

-Patients and families are tipped to be on the look-out for mood, motor or suicidal symptoms, and to immediately contact our office or the emergency department immediately for emergence of any worrisome motor or non-motor issues.

To read more books and articles by Michael S. Okun MD check Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #EndingPD and https://www.tourettetreatment.com/