1
|
Isaacson S, Phillips O, Jimenez-Shahed J. Hope vs. Hype III: Rescue/on-demand therapies are preferable to device-assisted therapies in Parkinson disease. Parkinsonism Relat Disord 2024; 126:106079. [PMID: 38503575 DOI: 10.1016/j.parkreldis.2024.106079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Affiliation(s)
- Stuart Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, 951 NW 13th St, Bldg. 5-E, Boca Raton, FL, 33486, USA.
| | - Oliver Phillips
- Geisel School of Medicine at Dartmouth, Hanover, 18 Old Etna Road, Lebanon, NH, 03756, USA.
| | - Joohi Jimenez-Shahed
- Icahn School of Medicine at Mount Sinai, Mount Sinai West, 1000 10th Ave. Suite 10c, New York City, NY, 10019, USA.
| |
Collapse
|
2
|
Pahwa R, Pagan FL, Kremens DE, Saint-Hilaire M. Clinical Use of On-Demand Therapies for Patients with Parkinson's Disease and OFF Periods. Neurol Ther 2023; 12:1033-1049. [PMID: 37221354 PMCID: PMC10310675 DOI: 10.1007/s40120-023-00486-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/19/2023] [Indexed: 05/25/2023] Open
Abstract
On-demand therapies for Parkinson's disease (PD) provide rapid, reliable relief for patients experiencing OFF periods; however, practical guidelines on the use of these therapies are not generally available. This paper reviews the use of on-demand treatments. Motor fluctuations occur in nearly all patients with PD after long-term use of levodopa. As the goal of PD treatment is to provide good ON time, on-demand treatments that have a more rapid reliable onset than the slower-acting oral medications provide rapid relief for OFF periods. All current on-demand treatments bypass the gastrointestinal tract, providing dopaminergic therapy directly into the blood stream by subcutaneous injection, through the buccal mucosa, or by inhalation into the pulmonary circulation. On-demand treatments are fast acting (10- to 20-min onset), with maximum, reliable, and significant responses reached within 30 min after administration. Oral medications pass through the gastrointestinal tract and thus have slower absorption owing to gastroparesis and competition with food. On-demand therapies, by providing fast-acting relief, can have a positive impact on a patient's quality of life when patients are experiencing OFF periods.
Collapse
Affiliation(s)
- Rajesh Pahwa
- Department of Neurology, University of Kansas Medical Center, 3599 Rainbow Blvd, Mailstop 2012, Kansas City, KS, 66160, USA.
| | - Fernando L Pagan
- Department of Neurology, Georgetown University Hospital, Washington, DC, USA
| | - Daniel E Kremens
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marie Saint-Hilaire
- Department of Neurology, Parkinson's Disease and Movement Disorders Center, Boston University School of Medicine, Boston, MA, USA
| |
Collapse
|
3
|
Jost WH, Kulisevsky J, LeWitt PA. Inhaled levodopa for threatening impending OFF episodes in managing Parkinson's disease. J Neural Transm (Vienna) 2023; 130:821-826. [PMID: 37087697 DOI: 10.1007/s00702-023-02636-3] [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: 02/26/2023] [Accepted: 04/16/2023] [Indexed: 04/24/2023]
Abstract
Parkinson's disease (PD) is a neurodegenerative disorder that leads to the degeneration of dopaminergic neurons resulting in a widespread pathology of motor and non-motor symptoms. Oral levodopa remains the most effective symptomatic treatment of PD, but motor complications such as Off episodes occur over time. The spectrum of manifestation of OFF episodes varies, e.g., early morning akinesia, end-of-dose wearing OFF, delayed ON, suboptimal ON and dose failure. The functional disability substantially impacts the quality of life for PD patients. An innovative on-demand therapy to treat Off episodes was approved for patients receiving oral levodopa/dopa deacarboxylase inhibitor: inhaled levodopa powder (Inbrija®). The pulmonary delivery of inhaled levodopa powder provides a predictable and fast treatment effect, independent of gastrointestinal dysfunctions or food intake, which could affect levodopa absorption. Levodopa is administered with a breath-actuated inhaler device and the approved dose is 84 mg per Off episode. During the pivotal SPAN-PD phase III trial, significant improvement in Unified Parkinson Disease Rating Scale III score was measured 30 min post-dose at week 12. Improvement was already seen for the first measured time point 10 min post-dose. No differences in pulmonary function was observed when using inhaled levodopa powder regularly for up to 12 months. Inhaled levodopa powder was also approved for early morning Off episodes. The aim of this review article is to give an overview of the different clinical studies of the innovative inhaled levodopa powder, a new on-demand therapy to treat Off episodes in PD.
Collapse
Affiliation(s)
- Wolfgang H Jost
- Parkinson-Klinik Ortenau, Kreuzbergstr. 12-16, 77709, Wolfach, Germany.
| | - Jaime Kulisevsky
- Movement Disorders Unit, Neurology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Biomedical Research Institute (IIB-Sant Pau), Barcelona, Spain
- Centro de Investigación en Red-Enfermedades Neurodegenerativas (CIBERNED), Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Peter A LeWitt
- Wayne State University School of Medicine (Sastry Foundation Endowed Chair in Neurology and Henry Ford Hospital), Detroit, MI, 48201, USA
| |
Collapse
|
4
|
Martinez-Nunez AE, LeWitt PA. Drugs to the Rescue: Comparison of On-Demand Therapies for OFF Symptoms in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2023:JPD230055. [PMID: 37182902 DOI: 10.3233/jpd-230055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Patients with Parkinson's disease often suffer from OFF symptoms disrupting their daily routines and adding to disabilities. Despite polypharmacy and adjustments to medication schedules, they often do not experience consistent relief from their motor symptoms. As the disease progresses, impaired gastric emptying may evolve, making it even more challenging for dopaminergic drugs to provide consistent results. This review focuses on a group of drugs that have the pharmacokinetic advantage of a much earlier onset of action by virtue of their non-oral routes of absorption. We compare the current marketed options: subcutaneous apomorphine, sublingual apomorphine, and inhaled levodopa. Subcutaneous apomorphine is the speediest to take effect, whereas sublingual apomorphine offers the longest clinical effect. Inhaled levodopa has the most favorable side effect profile among the three options. An inhaled form of apomorphine is currently under development, having passed safety and efficacy studies. Each of these drugs has unique characteristics for the user, including different side effect profiles and onset of action. The best choice for a patient will depend on individual needs and circumstances. In this review, we explore those nuances to allow clinicians to select the best option for their patients.
Collapse
Affiliation(s)
| | - Peter A LeWitt
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
- Department of Neurology and Sastry Foundation Endowed Chair In Neurology, Wayne State University School of Medicine, Detroit, MI, USA
| |
Collapse
|
5
|
The Clinical Development of Levodopa Inhalation Powder. Clin Neuropharmacol 2023; 46:66-78. [PMID: 36715241 PMCID: PMC10010694 DOI: 10.1097/wnf.0000000000000540] [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: 01/31/2023]
Abstract
ABSTRACT Oral levodopa is the most effective treatment for Parkinson disease, but OFF periods emerge over time. Gastrointestinal dysfunction and food effects impact levodopa absorption, contributing to unpredictable control of OFF periods. Inhaled levodopa powder (Inbrija) is approved for on-demand treatment of OFF periods in patients receiving oral levodopa-dopa decarboxylase inhibitors. The 84-mg dose is administered via a breath-actuated inhaler. It provides pulmonary delivery of levodopa to the systemic circulation and is taken when a patient has an OFF period in between doses of regular oral levodopa medication. The pivotal SPAN-PD trial in patients experiencing OFF periods on oral dopaminergic therapy showed that levodopa inhalation powder 84 mg produced significant improvement in Unified Parkinson Disease Rating Scale Part III score, as measured 30 minutes postdose at week 12, and improvement was seen as early as 10 minutes. More patients in the levodopa inhalation powder group turned ON within 60 minutes of treatment and remained ON at 60 minutes than in the placebo group. Levodopa inhalation powder can also be used to treat early-morning OFF periods and, when used for up to 12 months, produced no clinically significant differences in pulmonary function compared with an untreated cohort. Levodopa inhalation powder 84 mg increased plasma levodopa concentration rapidly and with less variability than oral levodopa/carbidopa (25/100 mg). Most common adverse event associated with levodopa inhalation powder is cough, found in ~15% of patients in the SPAN-PD trial; otherwise, reported adverse events were consistent with those known to be associated with oral levodopa.
Collapse
|
6
|
Tan AH, Lim SY, Lang AE. The microbiome-gut-brain axis in Parkinson disease - from basic research to the clinic. Nat Rev Neurol 2022; 18:476-495. [PMID: 35750883 DOI: 10.1038/s41582-022-00681-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 12/12/2022]
Abstract
Evidence for a close bidirectional link between the brain and the gut has led to a paradigm shift in neurology, especially in the case of Parkinson disease (PD), in which gastrointestinal dysfunction is a prominent feature. Over the past decade, numerous high-quality preclinical and clinical publications have shed light on the highly complex relationship between the gut and the brain in PD, providing potential for the development of new biomarkers and therapeutics. With the advent of high-throughput sequencing, the role of the gut microbiome has been specifically highlighted. Here, we provide a critical review of the literature on the microbiome-gut-brain axis in PD and present perspectives that will be useful for clinical practice. We begin with an overview of the gut-brain axis in PD, including the potential roles and interrelationships of the vagus nerve, α-synuclein in the enteric nervous system, altered intestinal permeability and inflammation, and gut microbes and their metabolic activities. The sections that follow synthesize the proposed roles of gut-related factors in the development and progression of, in responses to PD treatment, and as therapeutic targets. Finally, we summarize current knowledge gaps and challenges and delineate future directions for the field.
Collapse
Affiliation(s)
- Ai Huey Tan
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. .,Mah Pooi Soo & Tan Chin Nam Centre for Parkinson's & Related Disorders, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Shen Yang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Mah Pooi Soo & Tan Chin Nam Centre for Parkinson's & Related Disorders, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Anthony E Lang
- Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, Toronto, Ontario, Canada.,Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Tai W, Kwok PCL. Recent advances in drug delivery to the central nervous system by inhalation. Expert Opin Drug Deliv 2022; 19:539-558. [PMID: 35532357 DOI: 10.1080/17425247.2022.2074975] [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: 11/04/2022]
Abstract
INTRODUCTION Drugs need to enter the systemic circulation efficiently before they can cross the blood-brain barrier and reach the central nervous system. Although the respiratory tract is not a common route of administration for delivering drugs to the central nervous system, it has attracted increasing interest in recent years for this purpose. AREAS COVERED In this article, we compare pulmonary delivery to three other common routes (parenteral, oral, and intranasal) for delivering drugs to the central nervous system, followed by summarising the devices used to aerosolise neurological drugs. Recent studies delivering drugs for different neurological disorders via inhalation are then discussed to illustrate the strengths of pulmonary delivery. EXPERT OPINION Recent studies provide strong evidence and rationale to support inhaling neurological drugs. Since inhalation can achieve improved pharmacokinetics and rapid onset of action for multiple drugs, it is a non-invasive and efficient method to deliver drugs to the central nervous system. Future research should focus on delivering other small and macro-molecules via the lungs for different neurological conditions.
Collapse
Affiliation(s)
- Waiting Tai
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
| | - Philip Chi Lip Kwok
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, New South Wales 2006, Australia
| |
Collapse
|
8
|
Lau YH, Podlewska A, Ocloo J, Gupta A, Gonde C, Bloem BR, Chaudhuri KR. Does Ethnicity Influence Recruitment into Clinical Trials of Parkinson's Disease? JOURNAL OF PARKINSON'S DISEASE 2022; 12:975-981. [PMID: 35068418 DOI: 10.3233/jpd-213113] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Lack of participation of black and minority ethnic communities (BAME) in registered clinical trials is a concern as data emerging from these studies are used to licence new drugs or other interventions, even though findings made in such selected study populations have limited external validity in the aforesaid ethnic groups. OBJECTIVE We used Parkinson's disease (PD), the fastest rising neurodegenerative disorder in the world, as an exemplar condition to test our hypothesis that participants from BAME communities are underrepresented in clinical trials. METHODS A systematic search of clinical trials registered on a Clinicaltrials.gov database which queried for PD with racial distribution data from 2017 to 2021. RESULTS Out of 266 trials considered, 54 trials were published in peer reviewed journals. Among these, only 23 (42.65%) publications reported data regarding the racial distribution of the participants. Out of these, five studies involved mixed racial participation and two trials included black subjects. CONCLUSION We found that inclusion of under-represented BAME groups in recently published clinical trials is low, at only 21.57%, and is not even considered in most studies. Out of the reviewed trials, only 5 (21.75%) studies reported detailed demographic categories with black minorities enrolment. This constitutes a severe under-representation when compared to the proportion of Black or African American in the UK population (3%). Results of this study identified the need for better reporting of racial composition in clinical trials. We strongly recommend that future studies should consider ethnicity and other issues around diversity when designing and implementing the clinical trials, not only in the PD field but also beyond.
Collapse
Affiliation(s)
- Yue Hui Lau
- Institute of Psychiatry, Psychology & Neuroscience at King's College and King's College Hospital NHS Foundation Trust, London, UK.,Parkinson Foundation Centre of Excellence, King's College Hospital, London, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London), King's College Hospital NHS Foundation Trust, London, UK
| | - Aleksandra Podlewska
- Institute of Psychiatry, Psychology & Neuroscience at King's College and King's College Hospital NHS Foundation Trust, London, UK.,Parkinson Foundation Centre of Excellence, King's College Hospital, London, UK
| | - Josephine Ocloo
- National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London), King's College Hospital NHS Foundation Trust, London, UK
| | - Atul Gupta
- Paediatric Respiratory Medicine, King's College Hospital, London, UK
| | - Christopher Gonde
- Institute of Liver Studies, King's College Hospital, NHS Trust Foundation, London, UK
| | - Bastiaan R Bloem
- Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - K Ray Chaudhuri
- Institute of Psychiatry, Psychology & Neuroscience at King's College and King's College Hospital NHS Foundation Trust, London, UK.,Parkinson Foundation Centre of Excellence, King's College Hospital, London, UK
| |
Collapse
|
9
|
Thijssen E, den Heijer JM, Puibert D, van Brummelen EMJ, Naranda T, Groeneveld GJ. Safety and pharmacokinetics of multiple dosing with inhalable apomorphine (AZ-009), and its efficacy in a randomized crossover study in Parkinson's disease patients. Parkinsonism Relat Disord 2022; 97:84-90. [PMID: 35366574 DOI: 10.1016/j.parkreldis.2022.02.014] [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: 10/22/2021] [Revised: 02/14/2022] [Accepted: 02/20/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Apomorphine is used to treat OFF periods in Parkinson's disease (PD) patients. AZ-009 is a novel apomorphine formulation that delivers a thermally-generated aerosol to the deep lung via inhalation with a single breath. METHODS Part A was a randomized, placebo-controlled, double-blind study investigating the safety and pharmacokinetics of multiple ascending doses of AZ-009. PD patients (n = 24) received placebo or 2, 3 or 4 mg AZ-009 once daily for 5 days, followed by three times daily for 2 days with 2 h between doses. Part B was a double-blind crossover study in 8 PD patients who experience OFF periods. During an OFF state, patients received 4 mg AZ-009 and placebo on two consecutive days in a randomized order. MDS-UPDRS III and ON/OFF state were assessed pre- and post-dose. RESULTS Three times daily dosing with 2, 3 and 4 mg AZ-009 was relatively well tolerated with no apparent accumulation or changes in safety profile. Mild and transient throat irritation and cough were reported most often. AZ-009 was rapidly absorbed with median Tmax between 1 and 2 min. When corrected for placebo response, the maximum effect of 4 mg AZ-009 based on MDS-UPDRS III scores was observed at 10 and 30 min post-dose with mean (SD) reductions of 6.8 (9.4) and 6.1 (9.1) points respectively. Whereas 0% of patients turned ON after placebo, 50% turned ON 10 min after 4 mg AZ-009 treatment. CONCLUSION AZ-009 is rapidly systemically absorbed and safe to dose three times daily. AZ-009 could provide a faster-acting and easier to use formulation than currently available therapies.
Collapse
Affiliation(s)
- Eva Thijssen
- Centre for Human Drug Research (CHDR), Zernikedreef 8, 2333 CL, Leiden, Netherlands; Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA, Leiden, Netherlands
| | - Jonas M den Heijer
- Centre for Human Drug Research (CHDR), Zernikedreef 8, 2333 CL, Leiden, Netherlands; Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA, Leiden, Netherlands
| | - David Puibert
- Ferrer HealthTech, Diagonal 549, 08029, Barcelona, Spain
| | | | - Tatjana Naranda
- Alexza Pharmaceuticals, 2091 Stierlin Court, Mountain View, CA, 94043, USA
| | - Geert Jan Groeneveld
- Centre for Human Drug Research (CHDR), Zernikedreef 8, 2333 CL, Leiden, Netherlands; Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA, Leiden, Netherlands.
| |
Collapse
|
10
|
Glenardi G, Handayani T, Barus J, Mangkuliguna G. Inhaled Levodopa (CVT-301) for the Treatment of Parkinson Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Neurol Clin Pract 2021; 12:139-148. [PMID: 35747892 PMCID: PMC9208397 DOI: 10.1212/cpj.0000000000001143] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/21/2021] [Indexed: 11/15/2022]
Abstract
ABSTRACTPurposeof Review: To investigate the efficacy and safety of CVT-301 for motor fluctuation in Parkinson’s disease (PD).Recent Findings:This study demonstrated that the CVT-301 group had a higher proportion of patients achieving an ON state than the placebo group (OR=2.68; 95% CI: 1.86-3.86; p<0.00001). Moreover, CVT-301 had also shown to improve motor function by UPDRS-III score (SMD=3.83; 95% CI: 2.44-5.23; p<0.00001) and promote an overall improvement of PD by PGIC self-rating (OR=2.95; 95% CI: 1.78-4.9; p<0.00001). The most common adverse events encountered were respiratory symptoms (OR=12.18; 95% CI: 5.01-29.62; p<0.00001) and nausea (OR=3.95; 95% CI: 1.01-15.41; p=0.05).Summary:CVT-301 had the potential to be an alternative or even a preferred treatment for motor fluctuation in PD patients.
Collapse
Affiliation(s)
- Glenardi Glenardi
- School of Medicine and Health Sciences (GG, GM), Atma Jaya Catholic University of Indonesia, North Jakarta; Department of Neurology (TH), Syamsudin Hospital, Sukabumi, Indonesia; and Department of Neurology (JB), School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, North Jakarta
| | - Tutwuri Handayani
- School of Medicine and Health Sciences (GG, GM), Atma Jaya Catholic University of Indonesia, North Jakarta; Department of Neurology (TH), Syamsudin Hospital, Sukabumi, Indonesia; and Department of Neurology (JB), School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, North Jakarta
| | - Jimmy Barus
- School of Medicine and Health Sciences (GG, GM), Atma Jaya Catholic University of Indonesia, North Jakarta; Department of Neurology (TH), Syamsudin Hospital, Sukabumi, Indonesia; and Department of Neurology (JB), School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, North Jakarta
| | - Ghea Mangkuliguna
- School of Medicine and Health Sciences (GG, GM), Atma Jaya Catholic University of Indonesia, North Jakarta; Department of Neurology (TH), Syamsudin Hospital, Sukabumi, Indonesia; and Department of Neurology (JB), School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, North Jakarta
| |
Collapse
|
11
|
Son YJ, Miller DP, Weers JG. Optimizing Spray-Dried Porous Particles for High Dose Delivery with a Portable Dry Powder Inhaler. Pharmaceutics 2021; 13:pharmaceutics13091528. [PMID: 34575603 PMCID: PMC8470347 DOI: 10.3390/pharmaceutics13091528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 11/16/2022] Open
Abstract
This manuscript critically reviews the design and delivery of spray-dried particles for the achievement of high total lung doses (TLD) with a portable dry powder inhaler. We introduce a new metric termed the product density, which is simply the TLD of a drug divided by the volume of the receptacle it is contained within. The product density is given by the product of three terms: the packing density (the mass of powder divided by the volume of the receptacle), the drug loading (the mass of drug divided by the mass of powder), and the aerosol performance (the TLD divided by the mass of drug). This manuscript discusses strategies for maximizing each of these terms. Spray drying at low drying rates with small amounts of a shell-forming excipient (low Peclet number) leads to the formation of higher density particles with high packing densities. This enables ultrahigh TLD (>100 mg of drug) to be achieved from a single receptacle. The emptying of powder from capsules is directly proportional to the mass of powder in the receptacle, requiring an inhaled volume of about 1 L for fill masses between 40 and 50 mg and up to 3.2 L for a fill mass of 150 mg.
Collapse
Affiliation(s)
- Yoen-Ju Son
- Genentech, South San Francisco, CA 94080, USA;
| | | | - Jeffry G. Weers
- Cystetic Medicines, Inc., Burlingame, CA 94010, USA;
- Correspondence: ; Tel.: +1-650-339-3832
| |
Collapse
|
12
|
Lipp MM, Hickey AJ, Langer R, LeWitt PA. A technology evaluation of CVT-301 (Inbrija): an inhalable therapy for treatment of Parkinson's disease. Expert Opin Drug Deliv 2021; 18:1559-1569. [PMID: 34311641 DOI: 10.1080/17425247.2021.1960820] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: The most widely used pharmacological treatment for Parkinson's disease is levodopa, the precursor for dopamine formation in the brain. Over time, the effectiveness of levodopa declines, and patients experience motor fluctuations, or OFF periods. A levodopa formulation administered via a capsule-based oral inhaler provides a new delivery mechanism for levodopa that provides rapid relief of OFF periods.Areas covered: CVT-301 is a dry powder formulation designed to supply levodopa to the systemic circulation via pulmonary absorption. The technology, pharmacokinetics, efficacy, and safety data of this formulation are presented.Expert opinion: Oral inhalation is a novel method of administration for levodopa that bypasses the gastrointestinal tract, allowing levodopa to enter the systemic circulation rapidly and more reliably than oral medications. Gastrointestinal dysfunction, a common feature of Parkinson's disease, can lead to impaired absorption of oral medications. Pulmonary delivery rapidly elevates levodopa plasma concentrations to provide relief of OFF periods for patients receiving oral levodopa.
Collapse
Affiliation(s)
| | | | - Robert Langer
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Peter A LeWitt
- Department of Neurology, Henry Ford Hospital and Wayne State University School of Medicine, West Bloomfield, MI, USA
| |
Collapse
|
13
|
Hauser RA, LeWitt PA, Comella CL. On demand therapy for Parkinson's disease patients: Opportunities and choices. Postgrad Med 2021; 133:721-727. [PMID: 34082655 DOI: 10.1080/00325481.2021.1936087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Levodopa is the most effective symptomatic treatment for Parkinson's disease (PD), but a major treatment challenge is that over time, many patients experience periods of return of PD symptoms intermittently through the day, known as OFF periods. OFF periods typically manifest as a return of motor symptoms but can also involve non-motor symptoms and these periods can disrupt good control despite optimization of the oral levodopa regimen. OFF periods emerge in large measure due to a shortening of the duration of clinical benefit from oral levodopa, thought to be related to a progressive loss of dopamine neurons and their ability to store and release levodopa-derived dopamine over many hours. The problem is further compounded by impaired absorption of oral levodopa due to gastroparesis and other factors limiting its uptake in the small intestine, including competition for uptake by meals and their protein content. On-demand therapies are now available for the treatment of OFF episodes in PD and are administered intermittently, on an as-needed basis, on top of the patient's maintenance medication regimen. To be useful, an on-demand medication should take effect more rapidly and reliably than oral levodopa. Options for on-demand therapy for OFF periods have recently increased with the approval of levodopa inhalation powder and sublingual apomorphine as alternatives to the older option of subcutaneous apomorphine injection, each of which avoids the gastrointestinal tract and its potential for absorption delay. On-demand therapy is now available for patients experiencing episodic or intermittent need for rapid and reliable onset of benefit. On-demand therapy may also provide an alternative to more invasive treatment such as infusion of levodopa/carbidopa intestinal gel and for patients whose OFF episodes are not controlled despite deep brain stimulation.
Collapse
Affiliation(s)
- Robert A Hauser
- Parkinson's Disease and Movement Disorders Center, Department of Neurology, University of South Florida, Tampa, Florida, USA
| | - Peter A LeWitt
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA.,Parkinson's Disease and Movement Disorders Center Henry Ford Hospital, West Bloomfield, Michigan, USA
| | - Cynthia L Comella
- Department of Neurological Sciences, Section of Parkinson Disease and Movement Disorders, Rush University Medical Center, Chicago,Illinois, USA
| |
Collapse
|
14
|
Stocchi F, Vacca L, Grassi A, Torti M. An evaluation of the efficacy and value of CVT-301 for the treatment of Parkinson's disease. Expert Opin Pharmacother 2021; 22:965-972. [PMID: 33629617 DOI: 10.1080/14656566.2021.1895748] [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: 10/22/2022]
Abstract
Introduction: Levodopa is the most effective drug in the treatment of Parkinson's disease, but its chronic treatment is linked to the occurrence of motor complications with fluctuations of motor performance and dyskinesia. Unpredictable OFF episodes can be severe and disabling and current rescue medications cannot always be used safely. Rescue therapy is characterized by a rapid and predictable ON response and the safety profile of levodopa will represent a major advantage for patients affected by unresponsive OFF episodes.Areas covered: CVT-301 is a new inhaled formulation of LD recently developed as a self-administered treatment for OFF periods. Herein, the pharmacodynamic and pharmacokinetic properties, efficacy, and safety of CVT-301 are reviewed.Expert opinion: CVT-301 may offer several potential advantages including increased systemic bioavailability through pulmonary absorption, rapid onset of action, avoidance of first-pass drug metabolism, and less plasma level variability. It should be noted that the delivery device used has been described as relatively simple to use, but the few steps required to prepare and self-administer the dose can be challenging for PD patients during their OFF state. Additionally, resolution of an OFF episode requires the administration of two capsules of CVT-301, which further complicates the use of the device.
Collapse
Affiliation(s)
- Fabrizio Stocchi
- Neurology, Institute for Research and Medical Care IRCCS San Raffaele Pisana, Rome, Italy.,Department of Human Sciences and Quality of Life Promotion, San Raffaele University, Rome, Italy
| | - Laura Vacca
- Neurology, Institute for Research and Medical Care IRCCS San Raffaele Pisana, Rome, Italy
| | - Andrea Grassi
- Department of Neuroscience and Rehabilitation, Casa Di Cura Privata Del Policlinico, Milano, Italy
| | - Margherita Torti
- Neurology, Institute for Research and Medical Care IRCCS San Raffaele Pisana, Rome, Italy
| |
Collapse
|