If you’re living with Parkinson’s disease and your medications aren’t controlling your symptoms the way they used to, you may have heard about “advanced therapies” — options like deep brain stimulation (DBS) and continuous infusion therapies such as Vyalev and Onapgo. It’s natural to want to know which one is right for you. But the most useful starting question isn’t which therapy sounds best — it’s which advanced therapy is most appropriate for your specific symptoms, goals, lifestyle, and overall medical situation. This page is meant to help you understand how a movement disorder specialist thinks through that decision — not to promote any single therapy.
When Medications Alone Are No Longer Enough
For many people, Parkinson’s is well managed with oral medication for years. Over time, though, the same doses may start to feel less reliable. You might notice:
- Wearing off — your medication’s benefit fading before the next dose is due
- Motor fluctuations — unpredictable swings between “on” time (when medication is working) and “off” time (when symptoms return)
- Dyskinesia — involuntary, sometimes writhing or fidgeting movements that can appear when medication levels peak
- Declining control — needing more frequent doses, or feeling that adjustments no longer buy you the steadiness they once did
These changes don’t mean you’ve “run out of options.” They often mean it’s a reasonable time to talk with a movement disorder specialist about whether an advanced therapy could help smooth out your day.
What Are Advanced Parkinson’s Therapies?
Advanced therapies are treatments used when oral medication alone can no longer provide steady, predictable symptom control. Rather than adding yet another pill to an already complex schedule, these therapies aim to deliver more continuous, consistent benefit throughout the day.
They generally fall into two broad categories:
- Deep brain stimulation (DBS) — a surgically implanted device that delivers electrical stimulation to specific areas of the brain
- Infusion therapies — devices that deliver medication continuously, most often through a small tube under the skin
Both can reduce “off” time and motor fluctuations. Neither is a cure, and neither is universally better than the other. They work in different ways, involve different trade-offs, and suit different people.
Deep Brain Stimulation (DBS)
What it is
DBS uses thin electrodes, surgically placed in specific movement-related areas of the brain, connected to a small pulse generator implanted under the skin near the collarbone. The device delivers continuous, adjustable electrical stimulation that helps regulate the abnormal brain activity behind many Parkinson’s symptoms. The stimulation settings can be fine-tuned over time, and the system can be turned off or removed if needed.
Why appropriately selected patients consider it
For people who are well-suited to it, DBS can offer a meaningful change in daily life. In appropriately selected candidates, it is often considered because it can:
- Reduce motor fluctuations — helping smooth the swings between “on” and “off” time so the day feels more predictable
- Reduce dyskinesia — often by easing the involuntary movements directly, and by allowing medication changes that lessen them
- Lower day-to-day medication burden for some patients — some people are able to reduce their oral medication after DBS, which can also reduce medication-related side effects
- Be adjusted over the long term — because the stimulation is programmable, settings can be refined for years as symptoms evolve, without further surgery to change the therapy itself
These potential benefits apply to appropriately selected patients — which is why candidacy is evaluated carefully rather than assumed.
Limitations
- Requires brain surgery, which carries its own risks and a recovery period
- Generally does not improve symptoms that don’t respond to levodopa (with the exception of certain tremor)
- May not help — and in some cases can affect — symptoms such as balance, walking, or speech
- Requires programming visits to optimize settings, and the device needs battery management or eventual replacement
Who may be a good candidate
DBS is often considered for people whose symptoms still respond well to levodopa but who experience significant fluctuations or dyskinesia, or who have tremor that medication can’t control. Candidacy also depends on factors like cognitive health, psychiatric stability, and overall fitness for surgery — which is exactly why careful evaluation matters.
Infusion Therapies
Continuous medication delivery
Instead of taking medication in separate doses throughout the day, infusion therapies deliver it continuously through a small pump. The goal is to keep medication levels steadier — reducing the peaks and valleys that drive “on/off” fluctuations — without brain surgery. Because the medication itself is being delivered (rather than the brain being stimulated), these therapies work through a different mechanism than DBS.
Vyalev
Vyalev is a continuous, around-the-clock infusion of a levodopa-based medication, delivered under the skin through a small cannula connected to a wearable pump. It’s designed to provide steady levodopa delivery throughout the day and night without surgery inside the brain.
Onapgo
Onapgo is a continuous under-the-skin infusion of apomorphine, a dopamine agonist, delivered by a wearable pump — typically during waking hours. It offers another non-surgical route to more continuous symptom control for people with motor fluctuations.
A third infusion option, Duopa, delivers a levodopa gel directly into the small intestine through a surgically placed tube; it may come up in discussion depending on your situation. Your specialist can explain whether it’s relevant for you.
Common advantages
- Provide more continuous symptom control without brain surgery (for the under-the-skin options)
- Delivery rates can be adjusted, and the therapy can be paused or stopped
- May be an option for people who aren’t candidates for — or don’t wish to undergo — surgery
The practical realities of daily use
Infusion therapies work well for many people, but they do ask more of your daily routine than a pill schedule does. It helps to understand what’s involved before deciding:
- Infusion-site management — the medication is delivered through a cannula placed under the skin, and the site needs to be rotated and cared for regularly. Skin reactions, tenderness, or firm nodules can develop at infusion sites and may need attention.
- Daily pump responsibilities — the pump has to be set up, filled, started, and worn through the day (and, for some therapies, overnight). This becomes a routine part of daily life.
- Supply management — cannulas, medication cartridges, and related supplies need to be kept stocked, stored properly, and reordered on schedule so therapy isn’t interrupted.
- Caregiver involvement when applicable — some people manage all of this independently; others benefit from a caregiver’s help with setup, site care, or troubleshooting, particularly when dexterity or vision is a factor.
- Tolerability considerations — beyond the skin site, each medication has its own possible side effects, and finding a comfortable, effective delivery rate can take some adjustment early on.
- Device maintenance — pumps require care, charging or battery attention, and occasional troubleshooting, along with knowing how to respond if an alarm or interruption occurs.
For many people, these responsibilities are a very manageable trade-off for steadier symptom control. For others, the ongoing upkeep is a genuine factor to weigh. Neither reaction is wrong — it’s part of what makes the decision personal.
Why Advanced Therapies Are Not Interchangeable
It’s tempting to think of these therapies as different brands of the same thing — pick the one that sounds best. In reality, they suit different people for different reasons, and a therapy that is an excellent fit for one patient may be a poor fit for another patient with seemingly similar Parkinson’s symptoms. Two people with comparable tremor or fluctuations can still land on very different recommendations once the full picture is considered.
A movement disorder specialist weighs a range of factors together, including:
- Symptom profile — which symptoms trouble you most, and whether they respond to levodopa
- Cognitive status — some therapies are less suitable when there’s significant cognitive change
- Caregiver support — whether you have help available for device care and daily maintenance
- Age and overall health — which can affect both surgical candidacy and day-to-day management
- Medical comorbidities — other conditions that may make one approach safer or more practical than another
- Treatment goals — what “better” actually means to you, whether that’s fewer off periods, less dyskinesia, or a simpler routine
- Willingness to undergo surgery — a personal decision that legitimately shapes the options
- Tolerance for devices and ongoing maintenance — comfort with wearing a pump or managing an implanted system over time
These factors don’t sit in isolation — they interact. A consideration that points toward one therapy for one person may point the other way for someone else, depending on the rest of their situation. That’s why matching a therapy to a patient is a clinical judgment, not a menu choice.
Why Some Patients Are Evaluated for DBS Before Infusion Therapy
Advanced therapies aren’t always considered in the same order for everyone. Depending on the person, a movement disorder specialist may explore one path before another — and for a different patient, that order might be reversed. This isn’t because one therapy is better; it’s because the details of each person’s situation point toward evaluating a particular option first.
Factors that can influence the order of evaluation include:
- Symptom profile — the specific mix of tremor, fluctuations, dyskinesia, or medication-resistant symptoms
- Levodopa responsiveness — how clearly symptoms improve with levodopa, which is especially relevant to some options
- Cognition — cognitive health can make one pathway more suitable to explore first than another
- Overall health — including whether someone is well-positioned for a surgical procedure
- Treatment goals — what the person most wants to change about their daily experience
- Surgical candidacy — medical and practical factors that affect whether surgery is an appropriate first avenue
- Personal preference — including comfort with surgery versus wearing an external device
The takeaway isn’t that DBS should come first, or that infusion should — only that the sequence of evaluation is itself individualized. A thoughtful specialist starts from your situation and works outward, rather than applying a fixed order to everyone.
Why Independent Evaluation Matters
Much of the information patients encounter about advanced therapies comes from sources with something to promote. That’s why an independent evaluation is so valuable: the goal is not to choose a therapy first and fit you to it — it’s to determine which therapy best fits you.
An evaluation that isn’t tied to a predetermined treatment pathway can weigh every option on its merits for your situation. When a practice isn’t committed in advance to a particular device or procedure, the recommendation can follow the patient rather than the pathway.
Because the evaluation stays open to every outcome, it can genuinely go in any direction. In some cases, an evaluation may conclude that DBS is the most appropriate next step. In others, an infusion therapy may be a better fit. And sometimes the right answer is to continue optimizing medication and supportive therapies before pursuing an advanced therapy at all. Not every patient needs an advanced therapy, and a good evaluation is just as willing to reach that conclusion as any other.
The most productive place to start isn’t:
“I want DBS.” or “I want Vyalev.”
It’s:
“I want to understand which advanced therapy best fits my situation.”
From there, a movement disorder specialist can look at your symptoms, your response to medication, your treatment goals, and your circumstances, and help you weigh the real trade-offs — so that whatever you decide is a genuinely informed choice.
Talk With a Movement Disorder Specialist About Your Options
If you’re wondering whether an advanced therapy might help — or simply want to understand your options more clearly — the next step is a conversation, not a decision. A movement disorder specialist can review your symptoms, your response to current treatment, and your goals, and help you understand which paths make sense to consider for your situation. If you’d like to explore this with our team, you’re welcome to begin as a new patient.