Original Title: Avis: Utilisation de la tomoscintigraphie avec [ 123I]ioflupane (DaTscan) dans la démarche diagnostique de syndromes parkinsoniens

Authors' objectives: In light of concerns raised by the Association des médecins spécialistes en médecine nucléaire du Québec and the Association des neurologues du Québec, the Ministère de la Santé et des Services sociaux asked INESSS to issue recommendations on the use of the single-photon emission computed tomography (SPECT) with the radiotracer [ 123I]ioflupane. This test, which was approved by Health Canada in December 2017, permits visualization of the dopaminergic nerve endings in the central nervous system, thus making it easier to objectively confirm dopaminergic system degeneration, a hallmark of Parkinson's disease and other parkinsonian syndromes. SPECT is expensive and, given its newness, relatively inaccessible in Québec at this time. Since the number of requests for this test is likely to increase, overseeing its appropriate use is essential for ensuring access to the patients most likely to benefit from it.

Authors' results and conclusions: RESULTS: A total of 4 nuclear medicine practice guidelines, 7 clinical practice guidelines, 14 scientific reviews and 18 primary articles were selected. A recent health technology assessment report prepared by the Unité d'évaluation des technologies et des modes d'intervention en santé of the Centre hospitalier de l'Université de Montréal (CHUM) was also taken into consideration. The clinical indications and the evidence supporting them (diagnostic value and impact on management) were iteratively reviewed by the advisory committee for the purpose of issuing recommendations. Briefly, the clinical situations in which the use of ioflupane SPECT may be appropriate are broadly those where there is diagnostic uncertainty between a condition characterized by dopaminergic degeneration V (notably Parkinson's disease, Lewy body dementia, and other atypical parkinsonian syndromes) and a condition with a similar clinical presentation but with no dopaminergic loss (such as essential tremor, drug-induced or psychogenic parkinsonism, and Alzheimer's disease). In addition to specific clinical situations, the appropriate use of ioflupane SPECT rests primarily on identifying, based on clinical judgment, patients with sufficiently atypical symptomatology and/or a sufficiently uncertain diagnosis for confirmation by ioflupane SPECT to be likely to improve clinical management.

Authors' recommendations: With the goal of promoting the appropriate use of ioflupane SPECT and ensuring access to it by the patients who are most likely to benefit from it, this report proposes four main recommendations. WITH REGARD TO CLINICAL INDICATIONS: Recommendation 1: Ioflupane SPECT is not indicated for the routine diagnosis of movement disorders or dementia, for confirming an established clinical diagnosis, for monitoring disease progression, or as a substitute for a specialist consultation. Recommendation 2: Ioflupane SPECT may be indicated when the clinical diagnosis is still uncertain after a specialist consultation (usually in neurology or geriatrics) AND when the potential diagnostic clarification is considered likely to influence the patient’s management, e.g., modification of the treatment. The main indication in the area of movement disorders is for distinguishing Parkinson's disease from essential (or idiopathic) tremor, and that in the context of dementia is for distinguishing Lewy body dementia from Alzheimer's disease. More generally, ioflupane SPECT may be indicated for distinguishing dopaminergic degeneration (Parkinson's disease and atypical parkinsonian syndromes) from other, nondegenerative conditions with a similar presentation (see summary table of clinical indications). WITH REGARD TO ORGANIZATIONAL ARRANGEMENTS Recommendation 3: Ioflupane SPECT is a specialized test that should be ordered only after a consultation with a neurologist or geriatrician. Considering the high cost of and limited access to this test, and to reduce potentially inappropriate use as much as possible, hospitals that receive a large number of requests that are not in line with the disseminated clinical indications (recommendations 1 and 2) could, if they deem it necessary, set up a mechanism for evaluating and validating requests under the responsibility of their department of nuclear medicine and their movement disorders (or neurology) clinic. Recommendation 4: To support quality of care improvement, facilities that perform ioflupane SPECT should gather the relevant data on the requests they receive and the scans they perform (the patients’ clinical and sociodemographic characteristics, and the specific reasons for the requests) to permit a future evaluation of the relevant clinical indications and to optimize access to this diagnostic modality.

Authors' methods: A systematized search of appropriate use criteria in nuclear medicine, neurology clinical practice guidelines, scientific reviews and primary scientific articles was conducted to identify the clinical indications for the appropriate use of ioflupane SPECT. The literature search was organized around two research questions concerning the utility of ioflupane SPECT in the diagnostic process for movement disorders and dementias, respectively. The methodological quality of the selected publications was assessed, and information pertaining to the research questions (the clinical indications, the diagnostic value and impact of the test on clinical management, and the expertise of the clinicians who order the test) was extracted and submitted to an expert advisory committee (neurologists and nuclear medicine specialists) tasked with assisting in the interpretation of the identified literature and ruling on the relevance and applicability of the recommendations.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/utilisation-de-la-tomoscintigraphie-avec-123iioflupane-datscan-dans-la-demarche-diagnostique-de-syndromes-parkinsoniens.html

Year Published: 2021

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/utilisation-de-la-tomoscintigraphie-avec-123iioflupane-datscan-dans-la-demarche-diagnostique-de-syndromes-parkinsoniens.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec