Factors affecting the choice of first-line therapy in Parkinson's disease patients in Wales: A population-based study

Dopaminergic treatment strategies for people with Parkinson's disease in Europe: a retrospective analysis of PRISM trial data

BACKGROUND

Levodopa (LD) is the most effective drug to treat Parkinson's disease (PD). The recently concluded multinational Parkinson's Real-World Impact Assessment (PRISM) trial revealed highly variable prescription patterns of LD monotherapy across six European countries. The reasons remain unclear.

METHODS

In this post hoc analysis of PRISM trial data, we used multivariate logistic regression analysis to identify socio-economic factors affecting prescription practice. We applied receiver-operated characteristics and split sample validation to test model accuracy to predict treatment class (LD monotherapy vs. all other treatments).

RESULTS

Subject age, disease duration, and country of residence were significant predictors of treatment class. The chance of receiving LD monotherapy increased by 6.9% per year of age. In contrast, longer disease duration reduced the likelihood of receiving LD monotherapy by 9.7% per year. Compared to the other countries, PD patients in Germany were 67.1% less likely and their counterparts in the UK 86.8% more likely to receive an LD monotherapy. The model classification accuracy of treatment class assignment was 80.1%. The area under the curve to predict treatment condition was 0.758 (95% CI [0.715, 0.802]). Split sample validation revealed poor sensitivity (36.6%), but excellent specificity (92.7%) to predict treatment class.

CONCLUSION

The relative lack of socio-economic variables affecting prescription practice in the study sample and limited model accuracy to predict treatment class suggest the presence of additional, country-specific factors affecting prescription patterns that were not assessed in the PRISM trial. Our findings indicate that physicians still avoid prescribing LD monotherapy to younger PD patients.

Exercise-Boosted Mitochondrial Remodeling in Parkinson's Disease

Parkinson's disease (PD) is a movement disorder characterized by the progressive degeneration of dopaminergic neurons resulting in dopamine deficiency in the striatum. Given the estimated escalation in the number of people with PD in the coming decades, interventions aimed at minimizing morbidity and improving quality of life are crucial. Mitochondrial dysfunction and oxidative stress are intrinsic factors related to PD pathogenesis. Accumulating evidence suggests that patients with PD might benefit from various forms of exercise in diverse ways, from general health improvements to disease-specific effects and, potentially, disease-modifying effects. However, the signaling and mechanism connecting skeletal muscle-increased activity and brain remodeling are poorly elucidated. In this review, we describe skeletal muscle-brain crosstalk in PD, with a special focus on mitochondrial effects, proposing mitochondrial dysfunction as a linker in the muscle-brain axis in this neurodegenerative disease and as a promising therapeutic target. Moreover, we outline how exercise secretome can improve mitochondrial health and impact the nervous system to slow down PD progression. Understanding the regulation of the mitochondrial function by exercise in PD may be beneficial in defining interventions to delay the onset of this neurodegenerative disease.

Prescription Pattern of Monoamine Oxidase B Inhibitors Combined with Levodopa: A Retrospective Observational Analysis of Italian Healthcare Administrative Databases

BACKGROUND

Parkinson's disease is still incurable, and several factors are considered when defining pharmacological therapy.

OBJECTIVE

The aim of this study was to describe the prescription pattern of monoamine oxidase B inhibitors (MAO-BIs) marketed in Italy (selegiline, rasagiline, safinamide) as an add-on to levodopa among new users of MAO-BIs, from the perspective of the Italian National Health Service.

PATIENTS AND METHODS

Through cross-linkage of administrative healthcare data in the Ricerca e Salute (ReS) database, adults with a supply of one or more MAO-BIs in 2017, and with no other MAO-BI use since 2013, were selected. Levodopa had to be supplied within 30 days before/after the MAO-BI. The incidence, use, sex, age, comorbidities, 2-year prescription patterns (i.e., switches, proportion of treated patients per semester/year, mean daily milligrams/monthly tablets supplied, discontinuation, change to other anti-Parkinson drug) of patients taking MAO-BIs were provided.

RESULTS

In 2017, 1059 new users received an MAO-BI (incidence 22.6 × 100,000 adults) combined with levodopa: 502 subjects (10.7 × 100,000) were treated with selegiline, 161 (3.4 × 100,000) were treated with rasagiline, and 396 (8.4 × 100,000) were treated with safinamide. The cohorts mainly consisted of males with a median age of ≥ 74 years. Treatment incidences increased with age. Switches occurred in 18.0%, 11.0%, and 4.3% of the selegiline, rasagiline, and safinamide cohorts, respectively. Most of the patients switching from selegiline/safinamide changed to rasagiline, while most of the patients switching from rasagiline changed to safinamide. From the first to second years, patient numbers reduced by ≤ 50%, and the daily milligrams/monthly tablets slightly increased. Six-month discontinuation occurred in > 50% of all cohorts, and ≥ 65% of discontinuing patients changed to another anti-Parkinson drug.

CONCLUSIONS

This analysis described the heterogeneous use of MAO-BIs as an add-on to levodopa in Italy. Further clinical trials and real-world studies are encouraged to update the few existing guidelines and to align clinical practice strategies.

Trends and Contributing Factors for Prescribing Antipsychotics in Newly Diagnosed Parkinson's Disease Patients: A Population-Based Study

PURPOSE

Psychosis is very common in later stages of Parkinson's disease (PD) patients, but its prevalence in newly diagnosed patients is not rare. The use of antipsychotics in PD patients is complex given their association with worsening Parkinsonian motor symptoms and increased mortality rate. This study aims to examine factors that affect the use of antipsychotics in newly diagnosed PD patients and to identify changes in prescribing over time.

PATIENTS AND METHODS

The Secure Anonymized Information Linkage (SAIL) databank was used to identify a cohort of newly diagnosed PD patients aged 40 years and older in Wales. The cohort was longitudinally examined over 17 years to determine the incidence of new antipsychotic use. Logistic regression models were used to analyze the data and were adjusted for several potential confounding variables.

RESULTS

A total of 9142 PD patients were identified after applying inclusion and exclusion criteria, of whom 58.6% were male. During the first year of PD diagnosis, 12% of the patients developed psychosis and were prescribed antipsychotics. Quetiapine was the most commonly prescribed (49%), followed by risperidone (10.7%). The use of antipsychotics in newly diagnosed PD patients was significantly lower in the years 2009-2016 compared to 2000-2008 (OR 0.37, 95% CI 0.32-0.43). Other significant prescribing factors included patient's age and history of dementia.

CONCLUSION

A dramatic decline in antipsychotic use was identified across years, showing adherence to warnings against use of antipsychotics for PD patients. Given that psychosis is prevalent in PD patients, the continuous assessment of the safety risks of antipsychotics is a matter of priority.