Treatment of motor complications in Parkinson disease

Discontinue sinemet CR, MAOI, entacapone

Levodopa therapy

Dyskinesias

Motor fluctuations

Reduce levodopa

Add amantadine or amantadine ER, LCIG

Consider: zonisamide, clozapine, quetiapine, topiramate, levetiracetam

STN or GPi DBS

End

No improvement

SC or sublingual apomorphine, inhalable levodopa rescue continuous infusions:

LCIG
SC infusion apomorphine

Severe motor fluctuations

Fractionate levodopa or use
ER formulations
Add:

MAOI (rasagiline, selegiline, safinamide)
DA agonist (ER or transdermal formulations)
A2A antagonist (istradefylline)