Use of antiparkinson medications among elderly Medicare beneficiaries with Parkinson's disease

New horizons in Parkinson's disease in older populations

Parkinson's disease (PD) is the second most common neurodegenerative disorder after Alzheimer's disease. Ageing is considered to be the greatest risk factor for PD, with a complex interplay between genetics and the environment. With population ageing, the prevalence of PD is expected to escalate worldwide; thus, it is of utmost importance to reduce the burden of PD. To date, there are no therapies to cure the disease, and current treatment strategies focus on the management of symptoms. Older adults often have multiple chronic diseases and geriatric syndromes, which further complicates the management of PD. Healthcare systems and care models necessary to address the broad needs of older PD patients are largely unavailable. In this New Horizon article, we discuss various aspects of PD from an ageing perspective, including disease management. We highlight recent advancements in PD therapies and discuss new care models with the potential to improve patient's quality of life.

Levodopa Dose Equivalency in Parkinson's Disease: Updated Systematic Review and Proposals

BACKGROUND

To compare drug regimens across clinical trials in Parkinson's disease (PD) conversion formulae between antiparkinsonian drugs have been developed. These are reported in relation to levodopa as the benchmark drug in PD pharmacotherapy as 'levodopa equivalent dose' (LED). Currently, the LED conversion formulae proposed in 2010 by Tomlinson et al. based on a systematic review are predominantly used. However, new drugs with established and novel mechanisms of action and novel formulations of longstanding drugs have been developed since 2010. Therefore, consensus proposals for updated LED conversion formulae are needed.

OBJECTIVES

To update LED conversion formulae based on a systematic review.

METHODS

The MEDLINE, CENTRAL, and Embase databases were searched from January 2010 to July 2021. Additionally, in a standardized process according to the GRADE grid method, consensus proposals were issued for drugs with scarce data on levodopa dose equivalency.

RESULTS

The systematic database search yielded 3076 articles of which 682 were eligible for inclusion in the systematic review. Based on these data and the standardized consensus process, we present proposals for LED conversion formulae for a wide range of drugs that are currently available for the pharmacotherapy of PD or are expected to be introduced soon.

CONCLUSIONS

The LED conversion formulae issued in this Position Paper will serve as a research tool to compare the equivalence of antiparkinsonian medication across PD study cohorts and facilitate research on the clinical efficacy of pharmacological and surgical treatments as well as other non-pharmacological interventions in PD. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Antimuscarinic Anticholinergic Medications in Parkinson Disease: To Prescribe or Deprescribe?

The relative importance of antimuscarinic anticholinergic medications for Parkinson's disease (PD) declined after the introduction of levodopa, such that anticholinergic medications are now much more likely to be prescribed for clinical indications other than parkinsonism. Recent studies have found an association between anticholinergic medication exposure and future risk of dementia in older individuals and those with PD. These findings provide a further reason to avoid the use of anticholinergic medications to treat motor symptoms of PD. More importantly, they raise the question of whether one of the goals of PD treatment should be to deprescribe all medications with anticholinergic properties, regardless of their indication, to reduce dementia risk. In this review, we discuss the use of anticholinergic medications in PD, the evidence supporting the association between anticholinergic medications and future dementia risk, and the potential implications of these findings for clinical care in PD.

Prescription pattern of anti-Parkinson's disease drugs in Japan based on a nationwide medical claims database

Introduction

Parkinson's disease (PD) treatment should follow guidelines and be tailored to each patient. Large database analyses can provide insights into prescribing patterns.

Methods

Retrospective, cross-sectional study of patients (≥30 years) with PD diagnosis (ICD-10; schizophrenia/cerebrovascular disease excluded) using health insurance claims data (April 2008-December 2016) from the Japan Medical Data Vision database. Prescription patterns of anti-PD drugs were analysed by patient age and sex, calendar year, and overall.

Results

The analysis comprised 155,493 PD patient-years (56.1% women, mean 73.4 years). Patient number increased each year, mainly because of database expansion. L-dopa as monotherapy was the most common prescription (22.7% of patient-years); non-ergot dopamine agonists (DAs) were also common (7.6% as monotherapy, 6.8% with L-dopa). Monotherapy was prescribed for ~50% of patient-years, two drugs for 14.1%, and at least three drugs for 18.4%. Consistent with Japanese guidelines, L-dopa was mostly prescribed to older patients (≥60 years), whereas non-ergot DAs were mostly prescribed to middle-aged patients (peak at 50-69 years). Between 2008 and 2011, L-dopa prescription decreased while that of non-ergot DAs increased; this pattern reversed between 2012 and 2016.

Conclusion

These results indicate that Japanese clinicians are adhering to Japanese guidelines and tailoring anti-PD treatment to individual patients.

Adherence to treatment guideline recommendations for Parkinson's disease in Japan: A longitudinal analysis of a nationwide medical claims database between 2008 and 2016

Background

Adherence to the 2011 Japanese guidelines for treatment of Parkinson’s disease (PD) in real-life practice is unknown.

Methods

In this retrospective longitudinal observational study, we examined patterns and trends in anti-PD drug prescriptions in 20,936 patients (≥30 years of age with newly diagnosed PD [International Classification of Diseases–Tenth code G20 or PD Hoehn and Yahr scale 1–5] and one or more prescriptions) using nationwide registry data between 2008 and 2016. Data are presented as descriptive statistics.

Results

Half (49.6%) of the patients received levodopa (L-dopa) monotherapy, followed by non-ergot dopamine agonists (DA) prescribed as monotherapy (8.3%) or with L-dopa (8.1%). Consistent with the guidelines, 75% of patients were prescribed within 13 days of initial diagnosis; L-dopa monotherapy was the most prescribed drug in patients ≥70 years of age, whereas non-ergot DA monotherapy was more likely to be prescribed than L-dopa in patients between 30 and 50 years of age. Inconsistent with the guidelines, L-dopa monotherapy was the most prescribed drug in patients between 51 and 69 years of age. Over the course of 4 years of treatment, the prescription rate of L-dopa monotherapy and non-ergot DA monotherapy decreased by 63.7% and 44.1%, respectively, whereas that of L-dopa and non-ergot DA combination therapy increased by 103.7%. Combination therapy with L-dopa, non-ergot DA, and monoamine oxidase-B inhibitors was gradually increased at a later stage.

Conclusion

These results highlight that the state of PD treatment in Japan adheres to most of the recommendations in the 2011 national guidelines, but also precedes the 2018 guidelines.

Patterns and Determinants of Prescribing for Parkinson's Disease: A Systematic Literature Review

Since the discovery of levodopa (L-dopa) in 1967, the range of medications available to treat Parkinson's disease has increased significantly and guidance on the use, efficacy, and safety of these medications has evolved. To assess levels of adherence to national prescribing guidelines and awareness of changes in the efficacy and safety data published in the profiles of medications for the treatment of PD, we have reviewed studies on patterns and determinants of prescribing PD medications conducted in the last 50 years (since the discovery of L-dopa). A systematic literature review was conducted using EMBASE (1967 to March, 2018), Ovid MEDLINE(R) ALL (1967 to March 16, 2018), PsycINFO (1967 to the 2nd week of March, 2018), and PubMed to identify all studies measuring prescribing patterns of PD medication between 1967 and 2017. Study design, source of data, country, year of study, number of patients and/or prescriptions, unit of analysis, prescribing determinants, and percentage utilisation of PD medications were extracted where possible. 44 studies examining prescribing patterns and/or prescribing determinants across 17 countries were identified. Unsurprisingly, L-dopa was the most commonly prescribed medication in all studies, accounting for 46.50% to 100% of all prescriptions for PD. In several studies, the prescribing rate of ergot-derived dopamine agonists (DAs) decreased over time in concordance with guidance. In contrast, the prescribing rates of non-ergot DAs increased over the last ten years in most of the included studies. In examining prescribing factors, two major categories were exemplified, patients' factors and prescribers' factors, with patients' age being the most common factor that affected the prescription in most studies. In conclusion, L-dopa is now the most commonly prescribed medication for cases of PD but there is large variation in the prescribing rates of catechol-O-methyltransferase (COMT) inhibitors, monoamine oxidase B (MAO-B) inhibitors, amantadine, and anticholinergics between countries. New studies examining the effects of recent clinical trials and measuring the prescribing rates of newly approved medications are warranted.

Prevalence and Correlates of Anti-Parkinson Drug Use in a Nationally Representative Sample

BACKGROUND

Although numerous prescription drugs are available to treat Parkinson's disease (PD), little is known about national use in clinical practice and which factors may influence variability in care. The objectives of this study were to describe the prevalence of anti-Parkinson drug use among Medicare beneficiaries with PD and to identify demographic and clinical factors associated with drug use.

METHODS

This retrospective study was based on a random sample of annual 5% Medicare Part A and B claims linked with Medicare Part D drug files from 2007 through 2010. The study sample included fee-for-service Medicare beneficiaries with continuous stand-alone Part D enrollment who had been diagnosed with PD in the given year. First, any PD drug use and drug use by class (levodopa, dopamine agonist, anticholinerigc, monoamine oxidase B inhibitors, catechol-O-methyltransferase inhibitors, and amantadine) were described. Using generalized estimating equation regressions, patient and provider characteristics associated with anti-Parkinson drug use and choice were examined.

RESULTS

Over 81% of patients with PD were treated with anti-Parkinson drugs, and this proportion was stable over the 4 years of the study. The majority were treated with levodopa (90%); followed by dopamine agonists (29-31%); then monoamine oxidase B inhibitors, anticholinergics, amantadine, and catechol-O-methyltransferase inhibitors (all between 5% and 11%). Holding all else equal, patients who were not seen by a neurologist (odds ratio, 0.41; 95% confidence interval, 0.38-0.44; P < 0.001) and African-American patients (odds ratio, 0.80; 95% confidence interval, 0.69-0.93; P = 0.003) were significantly less likely to be treated.

CONCLUSIONS

Among a national sample of Medicare beneficiaries with PD, the majority received anti-Parkinson drugs. However, there was relative under-treatment of African-Americans and patients who were not seen by a neurologist for care.

Nursing home and end-of-life care in Parkinson disease

OBJECTIVE

To examine long-term care facility (LTCF or nursing home) use and end-of-life care for individuals with Parkinson disease (PD).

METHODS

In this nationwide retrospective cohort study, we compared LTCF and hospice utilization among Medicare beneficiaries diagnosed with PD by demographic, clinical, and physician characteristics. We also examined the impact of outpatient neurologist care for institutionalized patients with PD on end-of-life care.

RESULTS

We identified 469,055 individuals with PD who received Medicare benefits in 2002. Nearly 25% (more than 100,000 in total) resided in an LTCF. Women with PD had greater odds of nursing facility residence (adjusted odds ratio [AOR] 1.34, 95% confidence interval [CI] 1.30-1.38) compared with men. Black individuals with PD were 34% more likely than white individuals to reside in an LTCF (AOR 1.34, 95% CI 1.30-1.38), contrary to the race patterns typically observed for LTCF use. Hip fracture (AOR 2.10, 95% CI 2.04-2.15) and dementia (AOR 4.06, 95% CI 4.00-4.12) were the strongest clinical predictors of LTCF placement. Only 33% (n = 38,334) of nursing home residents with PD had outpatient neurologist care. Eighty-four percent (n = 80,877) of LTCF residents with PD died by December 31, 2005. Hospice utilization varied little by race and sex. LTCF residents who had outpatient neurologist care were twice as likely to utilize hospice services before death (AOR 2.35, 95% CI 2.24-2.47).

CONCLUSIONS AND RELEVANCE

A large proportion of the Medicare PD population resides in an LTCF. There is substantial unmet need for palliative care in the PD population. Increased efforts to provide specialist care to dependent individuals with PD may improve end-of-life care.