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Probst D, Batchu K, Younce JR, Sode K. Levodopa: From Biological Significance to Continuous Monitoring. ACS Sens 2024; 9:3828-3839. [PMID: 39047295 PMCID: PMC11348912 DOI: 10.1021/acssensors.4c00602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/21/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
A continuous levodopa sensor can improve the quality of life for patients suffering with Parkinson's disease by enhancing levodopa titration and treatment effectiveness; however, its development is currently hindered by the absence of a specific levodopa molecular recognition element and limited insights into how real-time monitoring might affect clinical outcomes. This gap in research contributes to clinician uncertainty regarding the practical value of continuous levodopa monitoring data. This paper examines the current state of levodopa sensing and the inherent limitations in today's methods. Further, these challenges are described, including aspects such as interference from the metabolic pathway and adjunct medications, temporal resolution, and clinical questions, with a specific focus on a comprehensive selection of molecules, such as adjunct medications and structural isomers, as an interferent panel designed to assess and validate future levodopa sensors. We review insights and lessons from previously reported levodopa sensors and present a comparative analysis of potential molecular recognition elements, discussing their advantages and drawbacks.
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Affiliation(s)
- David Probst
- Joint
Department of Biomedical Engineering, The
University of North Carolina at Chapel Hill and North Carolina State
University, Chapel Hill, North Carolina 27599, United States
| | - Kartheek Batchu
- Joint
Department of Biomedical Engineering, The
University of North Carolina at Chapel Hill and North Carolina State
University, Chapel Hill, North Carolina 27599, United States
| | - John Robert Younce
- Department
of Neurology, University of North Carolina
at Chapel Hill, Chapel
Hill, North Carolina 27599, United States
| | - Koji Sode
- Joint
Department of Biomedical Engineering, The
University of North Carolina at Chapel Hill and North Carolina State
University, Chapel Hill, North Carolina 27599, United States
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Ferreira JJ, Lee JY, Ma HI, Jeon B, Poewe W, Antonini A, Stocchi F, Rodrigues DM, Fonseca MM, Castilla-Fernández G, Holenz J, Rocha JF, Rascol O. Opicapone for the treatment of early wearing-off in levodopa-treated Parkinson's disease: pooled analysis of patient level data from two randomized open-label studies. J Neurol 2024:10.1007/s00415-024-12614-8. [PMID: 39164557 DOI: 10.1007/s00415-024-12614-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/25/2024] [Accepted: 07/28/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND The wearing-off phenomenon is a key driver of medication change for patients with Parkinson's disease (PD) treated with levodopa. Common first-line options include increasing the levodopa dose or adding a catechol-O-methyltransferase (COMT) inhibitor, but there are no trials comparing the efficacy of these approaches. We evaluated the effectiveness of adjunct opicapone versus an additional 100 mg levodopa dose in PD patients with early wearing-off using pooled data from 2 randomized studies. METHODS The ADOPTION study program included two similarly designed 4-week, open-label studies conducted in South Korea (NCT04821687) and Europe (NCT04990284). Patients with PD, treated with 3-4 daily doses of levodopa therapy and with signs of early wearing-off were randomized (1:1) to adjunct opicapone 50 mg or an additional dose of levodopa 100 mg. Patient-level data from the two studies were pooled. RESULTS The adjusted mean [SE] change from baseline to week 4 in absolute OFF time (key endpoint) was - 62.8 min [8.8] in the opicapone group and - 33.8 min [9.0] in the levodopa 100 mg group, the difference significantly favoring opicapone (- 29.0 [- 53.8, - 4.2] min, p = 0.02). Significant differences in the Movement Disorder Society-Unified Parkinson's Disease Rating Scale Part III subscore (- 4.1 with opicapone vs - 2.5 with levodopa 100 mg), also favored opicapone (- 1.7 [- 3.3, - 0.04], p < 0.05). Dyskinesia was the most frequently reported adverse event (opicapone 7.2% vs. levodopa 100 mg 4.2%). CONCLUSIONS In these short-term trials, introducing adjunct opicapone was more effective at reducing OFF time than adding another 100 mg levodopa dose in PD patients with early signs of wearing-off.
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Affiliation(s)
- Joaquim J Ferreira
- IMM - Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
- CNS - Campus Neurológico, Torres Vedras, Portugal.
| | - Jee-Young Lee
- Department of Neurology, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Hyeo-Il Ma
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Beomseok Jeon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Angelo Antonini
- Department of Neurosciences, University of Padova, Padua, Italy
| | - Fabrizio Stocchi
- University San Raffaele Roma and Institute for Research and Medical Care IRCCS San Raffaele, Rome, Italy
| | | | | | | | | | | | - Olivier Rascol
- Clinical Investigation Center CIC1436, Departments of Neurosciences and Clinical Pharmacology and NS-Park/FCRIN Network, University of Toulouse 3, University Hospital of Toulouse, INSERM, Toulouse, France
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3
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Lee J, Ma H, Ferreira JJ, Rocha J, Sung YH, Song I, Ahn T, Kwon DY, Cheon S, Kim J, Lee CS, Lee PH, Park J, Lee J, Park MY, Kim SJ, Baik JS, Choi S, Shin H, Lee H, Kang SY, Jeon B. Opicapone to Treat Early Wearing-off in Parkinson's Disease Patients: The Korean ADOPTION Trial. Mov Disord Clin Pract 2024; 11:655-665. [PMID: 38594812 PMCID: PMC11145137 DOI: 10.1002/mdc3.14030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/06/2024] [Accepted: 03/17/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Increasing levodopa (L-dopa)/dopa decarboxylase inhibitor (DDCI) daily dose or adding a catechol-O-methyltransferase (COMT) inhibitor to levodopa/DDCI therapy are strategies used to manage wearing-off symptoms in Parkinson's disease (PD) patients. OBJECTIVES To evaluate the COMT inhibitor opicapone versus an additional dose of levodopa to treat early wearing-off in PD patients. METHODS ADOPTION was a randomized, parallel-group, open-label, Phase 4 study conducted in Korea. At baseline, eligible patients were randomized (1:1) to opicapone 50 mg (n = 87) or L-dopa 100 mg (n = 81) (added to current L-dopa/DDCI therapy) for 4 weeks. The main efficacy endpoint was change from baseline to end of study in absolute off time. Other endpoints included changes in on time, in Movement Disorder Society-Unified Parkinson's Disease Rating Scale and 8-item PD Questionnaire scores, and the Clinical and Patient Global Impression of Improvement/Change. RESULTS The adjusted mean in absolute off time was significantly greater for opicapone 50 mg than for L-dopa 100 mg (-62.1 vs. -16.7 minutes; P = 0.0015). Opicapone-treated patients also reported a greater reduction in the percentage of off time (P = 0.0015), a greater increase in absolute on time (P = 0.0338) and a greater increase in the percentage of on time (P = 0.0015). There were no significant differences in other secondary endpoints. The L-dopa equivalent daily dose was significantly higher in the opicapone group (750.9 vs. 690.0 mg; P = 0.0247), when a 0.5 conversion factor is applied. CONCLUSIONS Opicapone 50 mg was more effective than an additional 100 mg L-dopa dose at decreasing off time in patients with PD and early wearing-off.
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Affiliation(s)
- Jee‐Young Lee
- Department of NeurologySMG‐SNU Boramae Medical CenterSeoulKorea
| | - Hyeo‐il Ma
- Department of NeurologyHallym University Sacred Heart HospitalAnyangKorea
| | - Joaquim J. Ferreira
- IMM – Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de LisboaLisbonPortugal
- CNS – Campus NeurológicoTorres VedrasPortugal
| | | | | | - In‐Uk Song
- The Catholic University of Korea Incheon St. Mary's HospitalIncheonKorea
| | | | | | | | - Jong‐Min Kim
- Seoul National University Bundang HospitalSeongnamKorea
| | | | | | - Jeong‐Ho Park
- Soon Chun Hyang University Hospital BucheonBucheonKorea
| | - Jae‐Hyeok Lee
- Pusan National University Yangsan HospitalYangsanKorea
| | | | | | | | - Seong‐Min Choi
- Chonnam National University Hospital, Chonnam National University Medical SchoolGwangjuKorea
| | | | - Ho‐Won Lee
- Kyungpook National University Chilgok HospitalDaeguKorea
| | - Suk Yun Kang
- Dongtan Sacred Heart Hospital Hallym University College of MedicineHwaseongKorea
| | - Beomseok Jeon
- Department of NeurologySeoul National University HospitalSeoulKorea
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Kassubek J, Jost WH, Schwarz J. Sublingual apomorphine in the treatment of Parkinson's disease. J Neural Transm (Vienna) 2024:10.1007/s00702-024-02777-z. [PMID: 38743091 DOI: 10.1007/s00702-024-02777-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/04/2024] [Indexed: 05/16/2024]
Abstract
Advanced Parkinson´s disease (PD) is often complicated by fluctuations of disability depending on plasma levels of levodopa. For most patients OFF phases with worsening of tremor and immobility, but also pain, depression, autonomic symptoms are troublesome. While adjustments of levodopa administrations can relief such fluctuations for some time, "on demand" therapies become more and more important. These "on demand" therapies should provide fast and efficacious relief. During the past years, new options for on demand therapies in PD-associated OFF episodes have been developed, including new formulations of levodopa and apomorphine to provide fast and readily accessible on demand treatment. In this narrative review, the challenges of the treatment of PD-associated fluctuations and OFF states are addressed, with a special focus on sublingual apomorphine (SL-APO) including the results from recent clinical trials.
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Affiliation(s)
- Jan Kassubek
- Department of Neurology, University Hospital Ulm, Ulm, Germany
- German Centre for Neurodegenerative Diseases (DZNE), Ulm, Germany
| | - Wolfgang H Jost
- Parkinson-Klinik Ortenau, Kreuzbergstr. 16, 77723, Wolfach, Germany.
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Bologna M, Guerra A, Colella D, Birreci D, Costa D, Cannavacciuolo A, Angelini L, Paparella G, Antonini A, Berardelli A, Fabbrini G. Objective assessment of the effects of opicapone in Parkinson's disease through kinematic analysis. Neurol Sci 2024; 45:2035-2046. [PMID: 38091213 PMCID: PMC11021230 DOI: 10.1007/s10072-023-07233-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Opicapone (OPC) is a third-generation, selective peripheral COMT inhibitor that improves peripheral L-DOPA bioavailability and reduces OFF time and end-of-dose motor fluctuations in Parkinson's disease (PD) patients. OBJECTIVES In this study, we objectively assessed the effects of adding OPC to L-DOPA on bradykinesia in PD through kinematic analysis of finger movements. METHODS We enrolled 20 treated patients with PD and motor fluctuations. Patients underwent two experimental sessions (L-DOPA, L-DOPA + OPC), separated by at least 1 week. In each session, patients were clinically evaluated and underwent kinematic movement analysis of repetitive finger movements at four time points: (i) before their usual morning dose of L-DOPA (T0), (ii) 30 min (T1), (iii) 1 h and 30 min (T2), and (iv) 3 h and 30 min after the L-DOPA intake (T3). RESULTS Movement velocity and amplitude of finger movements were higher in PD patients during the session with OPC compared to the session without OPC at all the time points tested. Importantly, the variability of finger movement velocity and amplitude across T0-T3 was significantly lower in the L-DOPA + OPC than L-DOPA session. CONCLUSIONS This study is the first objective assessment of the effects of adding OPC to L-DOPA on bradykinesia in patients with PD and motor fluctuations. OPC, in addition to the standard dopaminergic therapy, leads to significant improvements in bradykinesia during clinically relevant periods associated with peripheral L-DOPA dynamics, i.e., the OFF state in the morning, delayed-ON, and wearing-OFF periods.
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Affiliation(s)
- Matteo Bologna
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Università 30, 00185, Rome, Italy.
- IRCCS Neuromed, 86077, Pozzilli, IS, Italy.
| | - Andrea Guerra
- Parkinson and Movement Disorder Unit, Study Center On Neurodegeneration (CESNE), Department of Neuroscience, University of Padua, Padua, Italy
- Padua Neuroscience Center, University of Padua, Padua, Italy
| | - Donato Colella
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Università 30, 00185, Rome, Italy
| | - Daniele Birreci
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Università 30, 00185, Rome, Italy
| | - Davide Costa
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Università 30, 00185, Rome, Italy
| | | | - Luca Angelini
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Università 30, 00185, Rome, Italy
| | - Giulia Paparella
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Università 30, 00185, Rome, Italy
- IRCCS Neuromed, 86077, Pozzilli, IS, Italy
| | - Angelo Antonini
- Parkinson and Movement Disorder Unit, Study Center On Neurodegeneration (CESNE), Department of Neuroscience, University of Padua, Padua, Italy
- Padua Neuroscience Center, University of Padua, Padua, Italy
| | - Alfredo Berardelli
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Università 30, 00185, Rome, Italy
- IRCCS Neuromed, 86077, Pozzilli, IS, Italy
| | - Giovanni Fabbrini
- Department of Human Neurosciences, Sapienza University of Rome, Viale Dell'Università 30, 00185, Rome, Italy
- IRCCS Neuromed, 86077, Pozzilli, IS, Italy
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6
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Harrison-Jones G, Marston XL, Morgante F, Chaudhuri KR, Castilla-Fernández G, Di Foggia V. Opicapone versus entacapone: Head-to-head retrospective data-based comparison of healthcare resource utilization in people with Parkinson's disease new to catechol-O-methyltransferase (COMT) inhibitor treatment. Eur J Neurol 2023; 30:3132-3141. [PMID: 37489574 DOI: 10.1111/ene.15990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND AND PURPOSE Motor fluctuations are a significant driver of healthcare resource utilization (HCRU) in people with Parkinson's disease (pwPD). A common management strategy is to include catechol-O-methyltransferase (COMT) inhibition with either opicapone or entacapone in the levodopa regimen. However, to date, there has been a lack of head-to-head data comparing the two COMT inhibitors in real-world settings. The aim of this study was to evaluate changes in HCRU and effect on sleep medications when opicapone was initiated as first COMT inhibitor versus entacapone. METHODS In this retrospective cohort study, we assessed HCRU outcomes in pwPD naïve to COMT inhibition via UK electronic healthcare records (Clinical Practice Research Datalink and Hospital Episodes Statistics databases, June 2016 to December 2019). HCRU outcomes were assessed before (baseline) and after COMT inhibitor prescription at 0-6 months, 7-12 months and 13-18 months. Opicapone-treated pwPD were algorithm-matched (1:4) to entacapone-treated pwPD. RESULTS By 6 months, treatment with opicapone resulted in 18.5% fewer neurology outpatient visits compared to entacapone treatment; this effect was maintained until the last follow-up (18 months). In the opicapone group, the mean levodopa equivalent daily dose decreased over the first year and then stabilized, whereas the entacapone-treated group showed an initial decrease in the first 6 months followed by a dose increase between 7 and 18 months. Neither COMT inhibitor had a significant impact on sleep medication use. CONCLUSIONS This head-to-head study is the first to demonstrate, using 'real-world' data, that initiating COMT inhibition with opicapone is likely to decrease the need for post-treatment HCRU versus initiation of COMT inhibition with entacapone.
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Affiliation(s)
| | | | - Francesca Morgante
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St. George's University of London, London, UK
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - K Ray Chaudhuri
- Parkinson Foundation International Centre of Excellence, Kings College Hospital and Kings College London, London, UK
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Isaacson SH, Kremens D, Torres-Yaghi Y, Stocchi F, Antonini A. Importance of time to ON versus wearing OFF in total daily OFF time experienced by patients with Parkinson's disease. Parkinsonism Relat Disord 2023; 114:105495. [PMID: 37517986 DOI: 10.1016/j.parkreldis.2023.105495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 08/01/2023]
Abstract
Most patients with Parkinson's disease (PD) receiving levodopa (LD)/DOPA decarboxylase inhibitors develop motor fluctuations with an increasing amount of OFF time, negatively impacting patient quality of life. Herein, we review the evidence supporting the substantial, yet underappreciated contribution of delays in time to ON (including delayed ON and no ON) to total daily OFF time. Most clinical studies use patient diaries that do not capture time to ON and wearing OFF separately as related to LD dosing, and consequently, most OFF time has generally been attributed to wearing OFF. Hence, most treatment regimens focus on reducing wearing OFF by changing LD dosing/formulations and/or using "ON-extenders" (eg, catechol-o-methyltransferase inhibitors, monoamine oxidase-B inhibitors, extended-release amantadine, and adenosine A2A receptor antagonists). However, the literature describing approved treatments for PD that has focused on delays in time to ON is sparse and suggests this type of OFF may comprise more than twice the amount of total daily OFF time as wearing OFF. Here, we advocate for the importance of measuring and adequately addressing delays in time to ON and build support for the consistent inclusion of the time to ON measurement in future clinical trials.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, 951 NW 13th St, Bldg. 5-E, Boca Raton, FL, 33486, USA.
| | - Daniel Kremens
- Department of Neurology, Thomas Jefferson University, 901 Walnut Street, Suite 400, Philadelphia, PA, 19107, USA.
| | - Yasar Torres-Yaghi
- Department of Neurology, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, 7th Floor, PHC Building, Washington, DC, 20007, USA.
| | - Fabrizio Stocchi
- University San Raffaele Rome and Institute for Research and Medical Care IRCCS San Raffaele Pisana, Rome, Italy.
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Study Center on Neurodegeneration (CESNE), University of Padua, Padua, Italy.
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Campagnolo M, Emmi A, Biundo R, Fiorenzato E, Batzu L, Chaudhuri KR, Antonini A. The pharmacological management of the behavioral aspects of Parkinson's disease: an update. Expert Opin Pharmacother 2023; 24:1693-1701. [PMID: 37493445 DOI: 10.1080/14656566.2023.2240228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/20/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Behavioural symptoms are common manifestations of Parkinson's disease and include depression, anxiety, impulse control disorders, hallucinations, psychosis, and cognitive dysfunction. They remain inadequately addressed in many patients despite their relevance for quality of life and disability. This applies also to impulse control disorders where the most common approach in recent literature is to refrain from using dopamine agonists without consideration about their potential benefit on motor complications. AREAS COVERED We conducted a narrative review searching for articles on behavioral symptoms in Parkinson disease and selected those which included involved neurotransmitters such as dopamine, noradrenaline, serotonin, acetylcholine. We specifically focused our search on open-label and randomized double-blind studies and biomarkers which could best characterize these clinical manifestations. EXPERT OPINION Management of Parkinson disease behavioural manifestations lacks clear guidelines and standardized protocols beside general suggestions of dose adjustments in dopamine replacement therapy and use of antidepressants or antipsychotic drugs with little consideration of patients' age, sex, comorbidities, and motor status. We suggest a pragmatic approach which includes education of affected patients and caring people, dealing with complex cases by experienced multidisciplinary teams, use of cognitive behavioural therapy, and psychological counselling to complement drug treatment.
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Affiliation(s)
- Marta Campagnolo
- Parkinson's Disease and Movement Disorders Unit, Centre for Rare Neurological Diseases (ERN-RND), Department of Neuroscience, University of Padova, Padova, Italy
- Center for Neurodegenerative Disease Research (CESNE), Department of Neuroscience, University of Padova, Padova, Italy
| | - Aron Emmi
- Center for Neurodegenerative Disease Research (CESNE), Department of Neuroscience, University of Padova, Padova, Italy
- Institute of Human Anatomy, Department of Neuroscience, University of Padova, Padova, Italy
| | - Roberta Biundo
- Parkinson's Disease and Movement Disorders Unit, Centre for Rare Neurological Diseases (ERN-RND), Department of Neuroscience, University of Padova, Padova, Italy
- Center for Neurodegenerative Disease Research (CESNE), Department of Neuroscience, University of Padova, Padova, Italy
- Department of General Psychology, University of Padova, Padova, Italy
| | - Eleonora Fiorenzato
- Parkinson's Disease and Movement Disorders Unit, Centre for Rare Neurological Diseases (ERN-RND), Department of Neuroscience, University of Padova, Padova, Italy
| | - Lucia Batzu
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK
| | - K Ray Chaudhuri
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK
| | - Angelo Antonini
- Parkinson's Disease and Movement Disorders Unit, Centre for Rare Neurological Diseases (ERN-RND), Department of Neuroscience, University of Padova, Padova, Italy
- Center for Neurodegenerative Disease Research (CESNE), Department of Neuroscience, University of Padova, Padova, Italy
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Fabbri M, Barbosa R, Rascol O. Off-time Treatment Options for Parkinson's Disease. Neurol Ther 2023; 12:391-424. [PMID: 36633762 PMCID: PMC10043092 DOI: 10.1007/s40120-022-00435-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
Motor fluctuations (MF) are deemed by patients with Parkinson's disease (PD) as the most troublesome disease feature resulting from the increasing impairment in responsiveness to dopaminergic drug treatments. MF are characterized by the loss of a stable response to levodopa over the nychthemeron with the reappearance of motor (and non-motor) parkinsonian clinical signs at various moments during the day and night. They normally appear after a few years of levodopa treatment and with a variable, though overall increasing severity, over the disease course. The armamentarium of first-line treatment options has widened in the last decade with new once-a-daily compounds, including a catechol O-methyltransferase inhibitor - Opicapone-, two MAO-B inhibitors plus channel blocker - Zonisamide and Safinamide and one amantadine extended-release formulation - ADS5012. In addition to apomorphine injection or oral levodopa dispersible tablets, which have been available for a long time, new on-demand therapies such as apomorphine sublingual or levodopa inhaled formulations have recently shown efficacy as rescue therapies for Off-time treatment. When the management of MF becomes difficult in spite of oral/on-demand options, more complex therapies should be considered, including surgical, i.e. deep brain stimulation, or device-aided therapies with pump systems delivering continuous subcutaneous or intestinal levodopa or subcutaneous apomorphine formulation. Older and less commonly used ablative techniques (radiofrequency pallidotomy) may also be effective while there is still scarce data regarding Off-time reduction using a new lesional approach, i.e. magnetic resonance-guided focused ultrasound. The choice between the different advanced therapies options is a shared decision that should consider physician opinion on contraindication/main target symptom, patients' preference, caregiver's availability together with public health systems and socio-economic environment. The choice of the right/first add-on treatment is still a matter of debate as well as the proper time for an advanced therapy to be considered. In this narrative review, we discuss all the above cited aspects of MF in patients with PD, including their phenomenology, management, by means of pharmacological and advanced therapies, on-going clinical trials and future research and treatment perspectives.
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Affiliation(s)
- Margherita Fabbri
- Department of Clinical Pharmacology and Neurosciences, Toulouse Parkinson Expert Centre, Toulouse NeuroToul Center of Excellence in Neurodegeneration (COEN), French NS-Park/F-CRIN Network, University of Toulouse 3, CHU of Toulouse, INSERM, Toulouse, France.
| | - Raquel Barbosa
- Department of Clinical Pharmacology and Neurosciences, Toulouse Parkinson Expert Centre, Toulouse NeuroToul Center of Excellence in Neurodegeneration (COEN), French NS-Park/F-CRIN Network, University of Toulouse 3, CHU of Toulouse, INSERM, Toulouse, France.,Department of Neurology, Hospital de Egas Moniz Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas Universidade Nova de Lisboa, Lisbon, Portugal
| | - Olivier Rascol
- Department of Clinical Pharmacology and Neurosciences, Toulouse Parkinson Expert Centre, Toulouse NeuroToul Center of Excellence in Neurodegeneration (COEN), French NS-Park/F-CRIN Network, University of Toulouse 3, CHU of Toulouse, INSERM, Toulouse, France
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10
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Lees A, Tolosa E, Stocchi F, Ferreira JJ, Rascol O, Antonini A, Poewe W. Optimizing levodopa therapy, when and how? Perspectives on the importance of delivery and the potential for an early combination approach. Expert Rev Neurother 2023; 23:15-24. [PMID: 36729395 DOI: 10.1080/14737175.2023.2176220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION There is currently a resurgence of levodopa as the initial treatment of choice for most patients with Parkinson's disease, albeit at lower doses than previously used. The addition of adjuvant treatments (including MAO-B inhibitors, COMT inhibitors and dopamine agonists) is an established strategy to reduce motor complications that develop with sustained levodopa therapy. AREAS COVERED In this narrative review, the authors discuss the evidence underpinning current levodopa optimization strategies, during early disease and once motor complications occur. To support the discussion, the authors performed a broad PubMed search with the terms 'levodopa/L-dopa/L-Dopa, and Parkinson's disease,' restricted to clinical trials. There is now a wealth of evidence that improving levodopa delivery to the brain improves outcomes and we discuss how agents can be combined earlier in the course of disease to leverage the full potential of this strategy. EXPERT OPINION Levodopa remains the cornerstone of antiparkinsonian therapy. Several promising advances in formulation have been made and include novel extended-release oral drugs as well as non-oral delivery systems. However, evidence has long suggested that anti-parkinsonian medications may be better used in combination earlier in the disease, and consequently patients will benefit from low doses of several agents rather than ever larger levodopa doses.
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Affiliation(s)
- Andrew Lees
- University College London, Reta Lila Weston Institute, London, UK
| | - Eduardo Tolosa
- Parkinson disease and Movement Disorders Unit, Neurology Service, Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED: CB06/05/0018-ISCIII) Barcelona, Barcelona, Spain
| | - Fabrizio Stocchi
- Department of Neurology, University San Raffaele and IRCCS San Raffaele Pisana, Rome, Italy
| | - Joaquim J Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,CNS - Campus Neurológico, Torres Vedras, Portugal
| | - Olivier Rascol
- Department of Neurosciences and Clinical Pharmacology, Clinical Investigation center CIC1436 and NS-Park/FCRIN network; University Hospital of Toulouse, INSERM and University of Toulouse 3, Toulouse, France
| | - Angelo Antonini
- Movement Disorders Unit, Study Center for Neurodegenerative Diseases (CESNE), Department of Neuroscience, University of Padova
| | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Ashraf N. Tailoring Motor Fluctuation Treatment: Beyond Levodopa Dose Adjustment. EUROPEAN MEDICAL JOURNAL 2022. [DOI: 10.33590/emj/10022165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Susan Fox opened this satellite symposium at the 8th European Academy of Neurology (EAN) Congress with an overview of the concept of motor fluctuations (MF) in Parkinson’s disease (PD). She emphasised that levodopa remains the gold standard therapy for PD. However, MFs are one of the critical complications of levodopa therapy that affect many patients with advancing PD and, when diagnosed, represent a challenge in patient management. Alternative options are, therefore, needed to provide continuous dopaminergic stimulation while maximising the levodopa benefit. Despite different options, Angelo Antonini showed that neurologists often prefer to adjust levodopa dose rather than add an adjunctive agent. Market research confirms that, in patients with PD, the levodopa dose is adjusted in around 80% of patients, while only 20% have adjunct therapy as a first-line option. Adjusting the levodopa dose, either by increasing or fractionating the dose, or both, remains a valid, tried-and-tested option, although it has limitations. Joaquim Ferreira presented emerging evidence from a Phase II clinical trial, suggesting a potential benefit of adding opicapone 50 mg compared with 100 mg levodopa to treat patients with PD and end-of-dose fluctuations. This symposium aimed to present the effect of opicapone with relatively low total daily doses of levodopa; an option that may not have been traditionally considered by neurologists who are used to adjusting levodopa as a first-line response.
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