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Schröter N, Sajonz BEA, Jost WH, Rijntjes M, Coenen VA, Groppa S. Advanced therapies in Parkinson's disease: an individualized approach to their indication. J Neural Transm (Vienna) 2024:10.1007/s00702-024-02773-3. [PMID: 38613674 DOI: 10.1007/s00702-024-02773-3] [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: 02/18/2024] [Accepted: 03/25/2024] [Indexed: 04/15/2024]
Abstract
Device aided therapies (DAT) comprising the intrajejunal administration of levodopa/carbidopa intestinal gel (LCIG) and levodopa/carbidopa/entacapone intestinal gel (LECIG), the continuous subcutaneous application of foslevodopa/foscarbidopa or apomorphine infusion (CSAI) and deep brain stimulation (DBS) are used to treat Parkinson's disease with insufficient symptom alleviation under intensified pharmacotherapy. These DAT significantly differ in their efficacy profiles, indication, invasiveness, contraindications, and potential side effects. Usually, the evaluation of all these procedures is conducted simultaneously at the same point in time. However, as disease progression and symptom burden is extremely heterogeneous, clinical experience shows that patients reach the individual milestones for a certain therapy at different points in their disease course. Therefore, advocating for an individualized therapy evaluation for each DAT, requiring an ongoing evaluation. This necessitates that, during each consultation, the current symptomatology should be analyzed, and the potential suitability for a DAT be assessed. This work represents a critical interdisciplinary appraisal of these therapies in terms of their individual profiles and compares these DAT regarding contraindications, periprocedural considerations as well as their efficacy regarding motor- and non-motor deficits, supporting a personalized approach.
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Affiliation(s)
- Nils Schröter
- Department of Neurology and Clinical Neuroscience, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Bastian E A Sajonz
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Michel Rijntjes
- Department of Neurology and Clinical Neuroscience, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center of Deep Brain Stimulation, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sergiu Groppa
- Section of Movement Disorders and Neurostimulation, Department of Neurology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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2
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Antonini A, D'Onofrio V, Guerra A. Current and novel infusion therapies for patients with Parkinson's disease. J Neural Transm (Vienna) 2023; 130:1349-1358. [PMID: 37672049 PMCID: PMC10645652 DOI: 10.1007/s00702-023-02693-8] [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: 08/16/2023] [Accepted: 08/24/2023] [Indexed: 09/07/2023]
Abstract
Advanced Parkinson's disease is characterized by periods of poor mobility, dyskinesia and progressive decline in functional independence of the affected person despite the manipulation of levodopa doses and the introduction of supplemental therapies such as catechol-O-methyl transferase inhibitors, monoamine oxidase-B inhibitors and dopamine agonists. The implementation of drug delivery systems allows to bypass problems related to irregular and often unpredictable intestinal absorption of oral levodopa, which significantly affects its bioavailability and contributes to the development and persistence of motor complications. Subcutaneous apomorphine and levodopa/carbidopa jejunal infusion systems have been available for many years and their efficacy is confirmed by randomized studies and long-term experience in many centers worldwide. Recently, a new formulation of levodopa/carbidopa infusion gel that includes the catechol-O-methyl transferase inhibitor Entacapone has been introduced to the market. The use of entacapone allows to reduce total daily dose of administered levodopa. Two different soluble formulations of levodopa/carbidopa (ND0612 and ABBV-951) have completed clinical development, and both can ensure subcutaneous delivery by a portable pump infusion system. ABBV-951 uses a foslevodopa/foscarbidopa formulation, both prodrugs to improve absorption and tolerability. Both systems provide effective improvement of motor complications and are likely to expand the therapeutic options in advanced patients. Future efforts should focus on the earlier detection of patients who are candidates for device-aided therapies, increasing appropriate referral and broadening the availability of these treatments globally.
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Affiliation(s)
- Angelo Antonini
- Parkinson and Movement Disorders Unit, Centre for Rare Neurological Diseases (ERN-RND), Department of Neuroscience, University of Padua, Via Giustiniani 3, 35121, Padua, Italy.
- Padova Neuroscience Center (PNC), University of Padua, Padua, Italy.
| | | | - Andrea Guerra
- Parkinson and Movement Disorders Unit, Centre for Rare Neurological Diseases (ERN-RND), Department of Neuroscience, University of Padua, Via Giustiniani 3, 35121, Padua, Italy
- Padova Neuroscience Center (PNC), University of Padua, Padua, Italy
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3
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Taniwa K, Murakami K, Sakaguchi Y, Izuo N, Hanaki M, Sampa N, Kume T, Shimizu T, Irie K. Detection of Dietary Chalcone and Flavonoid Metabolites in Mice Using UPLC-MS/MS and Their Modulatory Effects on Amyloid β Aggregation. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2023; 71:14289-14299. [PMID: 37702279 DOI: 10.1021/acs.jafc.3c02598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Amyloid β-protein (Aβ42) aggregates have been demonstrated to induce cognitive decline and neurodegeneration in Alzheimer's disease (AD). Thus, functional food ingredients that inhibit Aβ42 aggregation are valuable for AD prevention. Although several food ingredients have been studied for their anti-aggregation activity, information on their bioavailability in the brain, incorporated forms, and relevance to AD etiology is limited. Here, we first detected the sulfate- and glucuronic-acid-conjugated forms of green perilla-derived chalcone (1) and taxifolin (2), which inhibit Aβ42 aggregation, in the brain, small intestine, and plasma of mice (1 and 2 were administered orally) using ultra-performance liquid chromatography-tandem mass spectrometry. We observed that the conjugated metabolites (sulfate (4) and glucuronide (5)) of 1 prevented the fibrillization and oligomerization of Aβ42. These findings imply that the conjugated metabolites of 1 can prove beneficial for AD treatment.
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Affiliation(s)
- Kota Taniwa
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Kyoto 606-8502, Japan
| | - Kazuma Murakami
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Kyoto 606-8502, Japan
| | - Yoshiki Sakaguchi
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Kyoto 606-8502, Japan
| | - Naotaka Izuo
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Mizuho Hanaki
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Kyoto 606-8502, Japan
| | - Nobuaki Sampa
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto 606-8501, Japan
| | - Toshiaki Kume
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, Kyoto University, Kyoto 606-8501, Japan
| | - Takahiko Shimizu
- Department of Endocrinology, Hematology and Gerontology, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Kazuhiro Irie
- Division of Food Science and Biotechnology, Graduate School of Agriculture, Kyoto University, Kyoto 606-8502, Japan
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Cochen De Cock V, Dodet P, Leu‐Semenescu S, Aerts C, Abril B, Castelnovo G, Landragin N, Drapier S, Olivet H, Corbillé A, Leclair‐Visonneau L, Anheim M, Vidailhet M, Arnulf I, Doulazmi M, Roze E. Night-Time Apomorphine Infusion: Who Are the Best Candidates? Mov Disord Clin Pract 2023; 10:1192-1197. [PMID: 37635769 PMCID: PMC10450238 DOI: 10.1002/mdc3.13799] [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: 02/14/2023] [Revised: 04/28/2023] [Accepted: 05/08/2023] [Indexed: 08/29/2023] Open
Abstract
Background We recently demonstrated in a randomized controlled trial (APOMORPHEE, NCT02940912) that night-time only subcutaneous apomorphine infusion improves sleep disturbances and insomnia in patients with advanced Parkinson's disease and moderate to severe insomnia. Objectives To identify the best candidates for receiving night-time only subcutaneous apomorphine infusion in routine care. Methods In this post-hoc analysis of APOMORPHEE, we compared the characteristics of patients according to whether they chose to continue night-time only subcutaneous apomorphine infusion at the end of the study period or not. Results Half of the patients (22/42) chose to continue the treatment. Off duration (day or night), painful Off dystonia, and insomnia severity at baseline were associated with night-time only apomorphine continuation. Multivariate analysis retained only Off duration as an independent predictor of continuation. Conclusions The best candidates for night-time only apomorphine are patients with severe and prolonged Off periods (day or night) and severe insomnia.
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Affiliation(s)
- Valérie Cochen De Cock
- Sleep and Neurology DepartmentBeau Soleil ClinicMontpellierFrance
- EuroMov Digital Health in MotionUniv Montpellier, IMT Mines AlèsMontpellierFrance
| | - Pauline Dodet
- Sleep Disorders UnitPitié‐Salpêtrière University HospitalParisFrance
| | | | - Cécile Aerts
- Sleep and Neurology DepartmentBeau Soleil ClinicMontpellierFrance
- EuroMov Digital Health in MotionUniv Montpellier, IMT Mines AlèsMontpellierFrance
| | - Beatriz Abril
- Sleep DepartmentUniversity Hospital of NîmesNîmesFrance
| | | | | | - Sophie Drapier
- Department of NeurologyPontchaillou INSERM CIC1414RennesFrance
| | - Hélène Olivet
- Sleep DepartmentPolyclinique Rennes Saint‐LaurentRennesFrance
| | | | - Laurène Leclair‐Visonneau
- Clinical Neurophysiology DepartmentUniversity Hospital of Nantes, INSERM U1235, Nantes UniversityNantesFrance
| | - Mathieu Anheim
- Department of NeurologyUniversity Hospital of StrasbourgStrasbourgFrance
- Genetic Institute and Molecular and Cellular Biology (IGBMC), INSERM‐U964/CNRS‐UMR7104/ Strasbourg UniversityIllkirchFrance
| | - Marie Vidailhet
- AP‐HP, Salpetriere Hospital, DMU Neuroscience 6ParisFrance
- Sorbonne University, Paris Brain Institute, Inserm, CNRSParisFrance
| | - Isabelle Arnulf
- Sleep Disorders UnitPitié‐Salpêtrière University HospitalParisFrance
- Sorbonne University, Paris Brain Institute, Inserm, CNRSParisFrance
| | - Mohamed Doulazmi
- Adaptation Biologique et Vieillissement (UMR8256), Institut de Biologie Paris Seine, Sorbonne University, CNRSParisFrance
| | - Emmanuel Roze
- AP‐HP, Salpetriere Hospital, DMU Neuroscience 6ParisFrance
- Sorbonne University, Paris Brain Institute, Inserm, CNRSParisFrance
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van Laar T, Chaudhuri KR, Antonini A, Henriksen T, Trošt M. Infusion Therapies in the Treatment of Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2023; 13:641-657. [PMID: 37334617 PMCID: PMC10473148 DOI: 10.3233/jpd-225112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/04/2023] [Indexed: 06/20/2023]
Abstract
Oral levodopa is the gold-standard therapy for treating Parkinson's disease (PD) but after a few years of treatment the therapeutic window narrows, and patients often experience various treatment-related complications. Patients in this advanced PD stage may benefit from alternative therapy, such as continuous intrajejunal delivery of levodopa-carbidopa intestinal gel (LCIG; or carbidopa-levodopa enteral suspension), continuous intrajejunal delivery of levodopa-carbidopa-entacapone intestinal gel, or continuous subcutaneous apomorphine infusion. Consideration and initiation of infusion therapies in advanced PD are suggested before the onset of major disability. The present review summarizes clinical evidence for infusion therapy in advanced PD management, discusses available screening tools for advanced PD, and provides considerations around optimal use of infusion therapy.
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Affiliation(s)
- Teus van Laar
- Department of Neurology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - K. Ray Chaudhuri
- Parkinson’s Foundation International Centre of Excellence, King’s College Hospital, London, UK
- Psychology & Neuroscience, King’s College Institute of Psychiatry, London, UK
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Study Center on Neurodegeneration (CESNE), Department of Neuroscience, Padua University, Padua, Italy
| | - Tove Henriksen
- Department of Neurology, Movement Disorder Clinic, University Hospital of Bispebjerg, Copenhagen, Denmark
| | - Maja Trošt
- Department of Neurology, University Medical Centre Ljubljana, Slovenia, Faculty of Medicine, University of Ljubljana, Slovenia
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6
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Jing XZ, Yang HJ, Taximaimaiti R, Wang XP. Advances in the Therapeutic Use of Non-Ergot Dopamine Agonists in the Treatment of Motor and Non-Motor Symptoms of Parkinson's Disease. Curr Neuropharmacol 2023; 21:1224-1240. [PMID: 36111769 PMCID: PMC10286583 DOI: 10.2174/1570159x20666220915091022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/25/2022] [Accepted: 07/18/2022] [Indexed: 11/22/2022] Open
Abstract
Dopamine (DA) agonists, as an excellent dopamine replacement therapy for patients with early and advanced Parkinson's disease (PD), play a vital role in controlling motor and several nonmotor symptoms. Besides, the application of DA agonists may delay levodopa therapy and the associated risk of motor complications. Indeed, each DA agonist has unique pharmacokinetic and pharmacodynamic characteristics and therefore has different therapeutic efficacy and safety profile. The comorbidities, significant non-motor manifestations, concomitant medications, and clinical features of PD individuals should guide the selection of a specific DA agonist to provide a more patient-tailored treatment option. Thorough knowledge of DA agonists helps clinicians better balance clinical efficacy and side effects. Therefore, this review refers to recent English-written articles on DA agonist therapy for PD patients and summarizes the latest findings on non-ergot DA agonists as well as the advantages and disadvantages of each compound to help clinicians in the selection of a specific DA agonist. In addition, novel D1/D5 partial agonists and new formulations of DA agonists are also discussed.
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Affiliation(s)
- Xiao-Zhong Jing
- Department of Neurology, Jiading Branch of Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
- Department of Neurology, TongRen Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Hui-Jia Yang
- Center for Clinical Research on Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian 116021, China
| | - Reyisha Taximaimaiti
- Department of Neurology, Jiading Branch of Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiao-Ping Wang
- Department of Neurology, Jiading Branch of Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
- Department of Neurology, TongRen Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
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7
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Urso D, Leta V, Rukavina K. Management strategies of sexual dysfunctions in Parkinson's disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 162:97-116. [PMID: 35397790 DOI: 10.1016/bs.irn.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Sexual dysfunctions (SD) are frequent and highly disabling nonmotor manifestations of Parkinson's disease (PD) but are also potentially treatable. Neurologists should actively discuss, recognize and treat sexual health issues as an integral part of the management of the disease. In this chapter, we provide recommendations for managing and treating both primary and secondary SD in PD. Many sexual problems can be, at least partially, improved by adjusting the treatment of motor, nonmotor symptoms and comorbidities. Although some treatments of primary SD are evidence-based, many therapeutic options have not been yet systematically studied in patients with PD. The development of new treatments and repurposing of existing remedies in patients with PD remain an unmet need.
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Affiliation(s)
- Daniele Urso
- King's College London, Department of Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom; Parkinson's Foundation Centre of Excellence, King's College Hospital, Denmark Hill, London, United Kingdom; Center for Neurodegenerative Diseases and the Aging Brain, Department of Clinical Research in Neurology, University of Bari 'Aldo Moro', "Pia Fondazione Cardinale G. Panico", Tricase, Lecce, Italy.
| | - Valentina Leta
- King's College London, Department of Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom; Parkinson's Foundation Centre of Excellence, King's College Hospital, Denmark Hill, London, United Kingdom
| | - Katarina Rukavina
- King's College London, Department of Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom; Parkinson's Foundation Centre of Excellence, King's College Hospital, Denmark Hill, London, United Kingdom
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8
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Personalised Advanced Therapies in Parkinson's Disease: The Role of Non-Motor Symptoms Profile. J Pers Med 2021; 11:jpm11080773. [PMID: 34442417 PMCID: PMC8400869 DOI: 10.3390/jpm11080773] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/25/2021] [Accepted: 07/26/2021] [Indexed: 12/22/2022] Open
Abstract
Device-aided therapies, including levodopa-carbidopa intestinal gel infusion, apomorphine subcutaneous infusion, and deep brain stimulation, are available in many countries for the management of the advanced stage of Parkinson’s disease (PD). Currently, selection of device-aided therapies is mainly focused on patients’ motor profile while non-motor symptoms play a role limited to being regarded as possible exclusion criteria in the decision-making process for the delivery and sustenance of a successful treatment. Differential beneficial effects on specific non-motor symptoms of the currently available device-aided therapies for PD are emerging and these could hold relevant clinical implications. In this viewpoint, we suggest that specific non-motor symptoms could be used as an additional anchor to motor symptoms and not merely as exclusion criteria to deliver bespoke and patient-specific personalised therapy for advanced PD.
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Meira B, Degos B, Corsetti E, Doulazmi M, Berthelot E, Virbel-Fleischman C, Dodet P, Méneret A, Mariani LL, Delorme C, Cormier-Dequaire F, Bendetowicz D, Villain N, Tarrano C, Mantisi L, Letrillart H, Louapre C, McGovern E, Worbe Y, Grabli D, Vidailhet M, Hainque E, Roze E. Long-term effect of apomorphine infusion in advanced Parkinson's disease: a real-life study. NPJ PARKINSONS DISEASE 2021; 7:50. [PMID: 34117268 PMCID: PMC8196159 DOI: 10.1038/s41531-021-00194-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/09/2021] [Indexed: 02/06/2023]
Abstract
Long-term effects of continuous subcutaneous apomorphine infusion (CSAI) on health-related quality of life (HRQoL) and predictors of CSAI discontinuation are poorly known. Data from consecutive advanced Parkinson’s disease patients treated in routine care were retrospectively collected over 24 months after CSAI initiation, with a focus on the 39-item Parkinson’s disease questionnaire (PDQ-39). We determined predictors of CSAI discontinuation and HRQoL improvement using multiple regression analysis. Of the 110 subjects evaluated over a 2-year period, 35% discontinued CSAI. Of those who continued treatment, HRQoL remained stable with a sustained reduction in motor fluctuations. The observed effect on dyskinesias was mild and transient. Of note, patients with preexisting impulse control disorders showed an overall good tolerability. PDQ-39 was the only baseline predictor of HRQoL improvement after 2 years of treatment. The presence of dyskinesias, poorer psychological status, shorter disease duration, male sex, and worse OFF state were predictors of discontinuation. Best candidates for CSAI are patients with: (i) poor baseline HRQoL and (ii) marked motor fluctuations.
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Affiliation(s)
- Bruna Meira
- Neurology Department, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Bertrand Degos
- Neurology Department, Avicenne Hospital, AP-HP, Sorbonne Paris Nord University, Bobigny, France
| | - Elise Corsetti
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Mohamed Doulazmi
- Adaptation Biologique et Vieillissement, Institut de Biologie Paris Seine, Sorbonne University, CNRS, Paris, France
| | - Emeline Berthelot
- Neurology Department, Hôpital Zobda Quitman, Fort-de-France, French West Indies, France
| | - Clara Virbel-Fleischman
- Air Liquide SA, Explor Center (Healthcare), Fort-de-France, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - Pauline Dodet
- Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France.,Sleep Disorders (Department "R3S"), Pitié-Salpêtrière Hospital, Paris, France
| | - Aurélie Méneret
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - Louise-Laure Mariani
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - Cécile Delorme
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - Florence Cormier-Dequaire
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - David Bendetowicz
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - Nicolas Villain
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France.,Sorbonne Université, GRC no 21, Alzheimer Precision Medicine, Paris, France
| | - Clément Tarrano
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - Lise Mantisi
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Hélène Letrillart
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Céline Louapre
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - Eavan McGovern
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Yulia Worbe
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Neurophysiology Department, Saint Antoine Hospital, AP-HP, Paris, France
| | - David Grabli
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - Marie Vidailhet
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - Elodie Hainque
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France
| | - Emmanuel Roze
- Neurology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France. .,Paris Brain Institute, Sorbonne University, UMR S 1127, Inserm U 1127, CNRS UMR 7225, Paris, France.
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11
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Müller T. An evaluation of subcutaneous apomorphine for the treatment of Parkinson's disease. Expert Opin Pharmacother 2020; 21:1659-1665. [PMID: 32640853 DOI: 10.1080/14656566.2020.1787379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Heterogeneity of symptoms and individual variability of progression characterizes Parkinson's disease. Unmet therapeutic needs include a cure, disease modification, and improvement of available marketed dopamine-substituting compounds. Personalized treatment, tailored to the patients' needs and symptoms, aims to ameliorate impaired motor behavior and non-motor features. Injection or infusion of apomorphine is a therapeutic option for more advanced patients with severe levodopa associated motor complications. AREAS COVERED This narrative review summarizes the subcutaneous administration, efficacy, and side effects of the non-ergot derivative dopamine agonist apomorphine following a non-systematic literature research. EXPERT OPINION Subcutaneous apomorphine hydrochloride application rapidly terminates intervals with severe motor impairment with bolus injections. Oscillation of motor behavior well responds to continuous apomorphine infusions. Long-term application of the commercially available apomorphine hydrochloride solution sooner or later affects skin and oral mucosa. Onset of skin nodules associated with subcutaneous tissue inflammation probably results from the antioxidant preservative sodium metabisulfite in the apomorphine solution. Addition of another better tolerated and safer antioxidant instead of sodium metabisulphite or use of an already available concentrated apomorphine-free base formulation will enhance its future use, its tolerability, safety, and acceptance of subcutaneous and sublingual application.
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Affiliation(s)
- Thomas Müller
- Department of Neurology, St. Joseph Hospital Berlin-Weißensee , Berlin, Germany
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12
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Vitale C, Amboni M, Erro R, Picillo M, Pellecchia MT, Barone P, Trojano L, Santangelo G. Parkinson’s disease management and impulse control disorders: current state and future perspectives. Expert Rev Neurother 2019; 19:495-508. [DOI: 10.1080/14737175.2019.1620603] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Carmine Vitale
- Department of Motor Sciences and Health, University “Parthenope”, Naples, Italy
| | - Marianna Amboni
- Neurodegenerative Diseases Center, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Roberto Erro
- Neurodegenerative Diseases Center, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Marina Picillo
- Neurodegenerative Diseases Center, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Maria Teresa Pellecchia
- Neurodegenerative Diseases Center, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Paolo Barone
- Neurodegenerative Diseases Center, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Luigi Trojano
- Department of Psychology, University “Luigi Vanvitelli”, Caserta, Italy
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13
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The next chapter in symptomatic Parkinson disease treatments. Parkinsonism Relat Disord 2019; 59:39-48. [DOI: 10.1016/j.parkreldis.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/01/2018] [Accepted: 01/02/2019] [Indexed: 01/19/2023]
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A Comparison of Pain between Parkinson's Disease and Multiple System Atrophy: A Clinical Cross-Sectional Survey. Pain Res Manag 2019; 2019:3150306. [PMID: 30805069 PMCID: PMC6362482 DOI: 10.1155/2019/3150306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 12/11/2018] [Accepted: 12/16/2018] [Indexed: 11/28/2022]
Abstract
Background Pain is frequent in Parkinson's disease (PD) and Parkinson-plus syndrome. This study aimed to assess the prevalence, characteristics, therapy (especially the effect of dopaminergic therapy), and associated symptoms of pain in Parkinson's disease and multiple system atrophy (MSA) patients. Methods Seventy-one PD patients, sixty-five MSA patients, and forty age-matched healthy controls were enrolled and evaluated by using the German pain questionnaire and visual analogue scale (VAS). In addition, the influence of pain in PD patients on anxiety, depression, and the quality of life was assessed with the Hospital Anxiety and Depression Scale (HADS) and Parkinson's Disease Questionnaire (PDQ-39). Results Compared to that of the healthy controls, the PD and MSA patients had a significantly higher presence of pain (P < 0.01, P < 0.01). PD patients had a higher presence of pain than MSA patients (P=0.007). No difference in VAS scores was observed between the PD and MSA patients (P=0.148). A total of 21 PD patients (42.85%) with pain and 13 MSA patients (43.33%) with pain received treatment. A total of 13 PD patients with pain and 6 MSA patients with pain had an improved pain intensity after using dopaminergic medication. The differences in the disease duration, Hoehn and Yahr stages, and scores on the Unified Parkinson's Disease Rating Scale motor score, HAD-D, HAD-A, and PDQ-39 were significant between the PD patients with and without pain. Conclusion PD and MSA patients are prone to pain with insufficient treatment. Pain interventions should be provided as soon as possible to improve the patient's life.
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Siddiqui J, Aldaajani Z, Mehanna R, Changizi BK, Bhatti D, Al-Johani ZG, Shukla AW, Fernandez HH, Bajwa JA. Rationale and patient selection for interventional therapies in Parkinson’s disease. Expert Rev Neurother 2018; 18:811-823. [DOI: 10.1080/14737175.2018.1535902] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Junaid Siddiqui
- Department of Neurology, Movement Disorders, University of Missouri, Columbia, MO, USA
| | - Zakiyah Aldaajani
- Department of Neurology, King Fahad Military Hospital, Dhahran, Saudi Arabia
| | - Raja Mehanna
- Department of Neurology, University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA
| | - Barbara Kelly Changizi
- Department of Neurology, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Danish Bhatti
- Department of Neurology, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Hubert H. Fernandez
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jawad A. Bajwa
- Parkinson’s, Movement Disorders and Neurorestoration Program, National Neuroscience Institute, Riyadh, Saudi Arabia
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ND0701, A Novel Formulation of Apomorphine for Subcutaneous Infusion, in Comparison to a Commercial Apomorphine Formulation: 28-Day Pharmacokinetic Study in Minipigs and a Phase I Study in Healthy Volunteers to Assess the Safety, Tolerability, Pharmacokinetics and Relative Bioavailability. CNS Drugs 2018; 32:443-454. [PMID: 29637529 DOI: 10.1007/s40263-018-0512-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Subcutaneous apomorphine is used for the treatment of Parkinson's disease (PD); however, infusion site reactions are a common adverse event (AE), which can lead to treatment discontinuation. Apomorphine formulations that are more tolerable and convenient for use are needed. OBJECTIVE Our aim was to compare the toxicity and bioavailability of ND0701, a new concentrated formulation of apomorphine free base, with one of the commercially available apomorphine HCl formulations (APO-go®, Britannia Pharmaceuticals Ltd). METHODS (1) Preclinical study: 16 minipigs were randomly assigned to placebo, APO-go®, and ND0701 groups, and treated for 28 days. Pharmacokinetic, clinical, and pathological assessments were performed. (2) Phase I study: 18 healthy volunteers participated in an open-label, two-sequence, randomized, three single-dose, partial crossover study to compare the pharmacokinetics, safety, and tolerability of ND0701 with APO-go® (1%). RESULTS (1) Preclinical study: No systemic toxicity was observed in apomorphine-treated minipigs, but local skin reactions were observed at the infusion sites. These effects were less frequent and less severe and recovery was more rapid for ND0701 compared with APO-go®. (2) Phase I study: Both formulations were safe and well tolerated under the conditions of the study and no severe or serious treatment-emergent AEs were reported. Infusion site nodules were reported more frequently, with higher severity, and recovered slower at APO-go®-treated sites compared with ND0701-treated sites. Bioavailability of apomorphine was comparable between the two formulations. CONCLUSION Based on these pilot studies, ND0701 appears to be superior to APO-go® in terms of tolerability and safety, while maintaining comparable bioavailability with APO-go®, and shows promise as a future treatment for PD.
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Pharmacological Insights into the Use of Apomorphine in Parkinson’s Disease: Clinical Relevance. Clin Drug Investig 2018; 38:287-312. [DOI: 10.1007/s40261-018-0619-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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18
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Fernández-Pajarín G, Sesar Á, Ares B, Castro A. Evaluating the Efficacy of Nocturnal Continuous Subcutaneous Apomorphine Infusion in Sleep Disorders in Advanced Parkinson's Disease: The APO-NIGHT Study. JOURNAL OF PARKINSONS DISEASE 2017; 6:787-792. [PMID: 27662329 DOI: 10.3233/jpd-160886] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There are not many data about the beneficial effect of nocturnal continuous subcutaneous apomorphine infusion (NCSAI) over sleep disturbances in advanced Parkinson's disease (PD). OBJECTIVE Evaluate the effect of the NCSAI in sleeping problems and insomnia due to nocturnal hypokinesia inadvanced PD. METHODS We assessed 17 advanced PD patients with several sleep disturbances measured by SCOPA-SLEEP and PDSS scales. All the patients were on apomorphine infusion during daytime. This therapy was extended to nighttime. We evaluated the patients before the onset and after six weeks with NCSAI. RESULTS NCSAI allowed highly significant improvements in SCOPA-SLEEP and PDSS scales (p<0.0001), and daytime somnolence. NCSAI was well tolerated with no major adverse effects were noticed. CONCLUSION This study shows and confirms the efficacy of NCSAI on the sleep disturbances related to advanced PD. We provide an easy protocol to start this therapy.
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Shaltiel-Karyo R, Tsarfati Y, Rubinski A, Zawoznik E, Weinstock I, Nemas M, Schiffenbauer YS, Ramot Y, Nyska A, Yacoby-Zeevi O. Magnetic Resonance Imaging as a Noninvasive Method for Longitudinal Monitoring of Infusion Site Reactions Following Administration of a Novel Apomorphine Formulation. Toxicol Pathol 2017; 45:472-480. [DOI: 10.1177/0192623317706111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Infusion site reactions are common following subcutaneous infusion of drugs. Such reactions can lead to discontinuation of the treatment. Therefore, assessment of such reactions is essential during preclinical safety studies, and magnetic resonance imaging (MRI) can assist in evaluation. Here, in vivo and ex vivo MRI evaluations were used in addition to classical histopathology to assess the infusion site reaction to ND0701, a novel formulation of apomorphine base developed for the treatment of Parkinson’s disease, in comparison to the commercial apomorphine hydrochloride (HCl) formulation. Both formulations, each at two concentrations, were continuously administered subcutaneously for 20 hr to each of 3 male and 3 female domestic pigs. Based on MRI evaluations, there was a gradual decrease in the volume of the subcutaneous lesions over 4 weeks, with smaller lesions and quicker resolution with ND0701 at concentrations 2.5- to 5-fold higher when compared to the commercial apomorphine HCl formulation. Histopathological evaluation of ND0701 revealed only minimal inflammation at the sites of infusion, whereas the commercial apomorphine HCl caused persistent inflammatory reactions and necrosis. This study provides support to the use of MRI in preclinical testing of subcutaneous drugs when evaluating local site reactions.
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Affiliation(s)
| | | | | | | | | | | | | | - Yuval Ramot
- Hadassah–Hebrew University Medical Center, Jerusalem, Israel
| | - Abraham Nyska
- Sackler School of Medicine, Tel Aviv University, Israel
- Consultant in Toxicologic Pathology, Timrat, Israel
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Sesar Á, Fernández-Pajarín G, Ares B, Rivas MT, Castro A. Continuous subcutaneous apomorphine infusion in advanced Parkinson’s disease: 10-year experience with 230 patients. J Neurol 2017; 264:946-954. [DOI: 10.1007/s00415-017-8477-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 03/26/2017] [Accepted: 03/27/2017] [Indexed: 11/29/2022]
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Ffytche DH, Creese B, Politis M, Chaudhuri KR, Weintraub D, Ballard C, Aarsland D. The psychosis spectrum in Parkinson disease. Nat Rev Neurol 2017; 13:81-95. [PMID: 28106066 PMCID: PMC5656278 DOI: 10.1038/nrneurol.2016.200] [Citation(s) in RCA: 207] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In 2007, the clinical and research profile of illusions, hallucinations, delusions and related symptoms in Parkinson disease (PD) was raised with the publication of a consensus definition of PD psychosis. Symptoms that were previously deemed benign and clinically insignificant were incorporated into a continuum of severity, leading to the rapid expansion of literature focusing on clinical aspects, mechanisms and treatment. Here, we review this literature and the evolving view of PD psychosis. Key topics include the prospective risk of dementia in individuals with PD psychosis, and the causal and modifying effects of PD medication. We discuss recent developments, including recognition of an increase in the prevalence of psychosis with disease duration, addition of new visual symptoms to the psychosis continuum, and identification of frontal executive, visual perceptual and memory dysfunction at different disease stages. In addition, we highlight novel risk factors - for example, autonomic dysfunction - that have emerged from prospective studies, structural MRI evidence of frontal, parietal, occipital and hippocampal involvement, and approval of pimavanserin for the treatment of PD psychosis. The accumulating evidence raises novel questions and directions for future research to explore the clinical management and biomarker potential of PD psychosis.
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Affiliation(s)
- Dominic H Ffytche
- KCL-PARCOG group, Institute of Psychiatry, Psychology &Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology &Neuroscience, King's College London, UK. De Crespigny Park, London SE5 8AF, UK
| | - Byron Creese
- KCL-PARCOG group, Institute of Psychiatry, Psychology &Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
- University of Exeter Medical School, University of Exeter, EX1 2LU, UK
| | - Marios Politis
- KCL-PARCOG group, Institute of Psychiatry, Psychology &Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
- Neurodegeneration Imaging Group, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology &Neuroscience, King's College London, 125 Coldharbour Lane, London SE5 9NU, UK
| | - K Ray Chaudhuri
- KCL-PARCOG group, Institute of Psychiatry, Psychology &Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, National Parkinson Foundation Centre of Excellence, King's College London/Kings College Hospital, 5 Cutcombe Road, London SE5 9RT, UK
| | - Daniel Weintraub
- KCL-PARCOG group, Institute of Psychiatry, Psychology &Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
- Departments of Psychiatry and Neurology, Perelman School of Medicine at the University of Pennsylvania 3615 Chestnut Street, #330, Philadelphia, Pennsylvania 19104, USA
- Parkinson's Disease and Mental Illness Research, Education and Clinical Centres (PADRECC and MIRECC), Philadelphia Veterans Affairs Medical Centre 3900 Woodland Avenue, Philadelphia, Pennsylvania 19104, USA
| | - Clive Ballard
- KCL-PARCOG group, Institute of Psychiatry, Psychology &Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
- University of Exeter Medical School, University of Exeter, EX1 2LU, UK
| | - Dag Aarsland
- KCL-PARCOG group, Institute of Psychiatry, Psychology &Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology &Neuroscience, King's College London, UK. De Crespigny Park, London SE5 8AF, UK
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ffytche DH, Aarsland D. Psychosis in Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 133:585-622. [DOI: 10.1016/bs.irn.2017.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Jenner P, Katzenschlager R. Apomorphine - pharmacological properties and clinical trials in Parkinson's disease. Parkinsonism Relat Disord 2016; 33 Suppl 1:S13-S21. [PMID: 27979722 DOI: 10.1016/j.parkreldis.2016.12.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 11/25/2016] [Accepted: 12/05/2016] [Indexed: 11/15/2022]
Abstract
Apomorphine is often considered an archetypal dopamine agonist used in the treatment of Parkinson's disease (PD). However, it can be clearly differentiated from most other commonly used dopamine agonists on the basis of its pharmacology and on its unique clinical profile. Like levodopa and dopamine, apomorphine acts as a potent, direct and broad spectrum dopamine agonist activating all dopamine receptor subtypes. It also has affinity for serotonin receptors, and α-adrenergic receptors. Apomorphine is usually titrated to a dose that provides an equivalent antiparkinsonian response to that provided by levodopa, and its subcutaneous delivery allows a rapid onset of action, usually within 7-10 min. The mode of apomorphine delivery impacts on its clinical profile so as to provide two very different approaches to therapy in PD. When administered as an acute subcutaneous injection, it induces reliable and rapid relief from OFF periods underscoring its utility as a rescue medication. When given as a subcutaneous infusion, it significantly improves overall daily OFF time and there is also evidence to suggest that, in those patients who replace most or all of their oral drugs with apomorphine infusion, dyskinesia may also improve. In this paper, we review the rich pharmacology of apomorphine and review its efficacy in PD based on data from clinical trials.
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Affiliation(s)
- Peter Jenner
- Neurodegenerative Diseases Research Group, Institute of Pharmaceutical Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.
| | - Regina Katzenschlager
- Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Danube Hospital, Vienna, Austria.
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Gastrointestinal Dysfunctions in Parkinson's Disease: Symptoms and Treatments. PARKINSONS DISEASE 2016; 2016:6762528. [PMID: 28050310 PMCID: PMC5168460 DOI: 10.1155/2016/6762528] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 10/16/2016] [Indexed: 12/21/2022]
Abstract
A diagnosis of Parkinson's disease is classically established after the manifestation of motor symptoms such as rigidity, bradykinesia, and tremor. However, a growing body of evidence supports the hypothesis that nonmotor symptoms, especially gastrointestinal dysfunctions, could be considered as early biomarkers since they are ubiquitously found among confirmed patients and occur much earlier than their motor manifestations. According to Braak's hypothesis, the disease is postulated to originate in the intestine and then spread to the brain via the vagus nerve, a phenomenon that would involve other neuronal types than the well-established dopaminergic population. It has therefore been proposed that peripheral nondopaminergic impairments might precede the alteration of dopaminergic neurons in the central nervous system and, ultimately, the emergence of motor symptoms. Considering the growing interest in the gut-brain axis in Parkinson's disease, this review aims at providing a comprehensive picture of the multiple gastrointestinal features of the disease, along with the therapeutic approaches used to reduce their burden. Moreover, we highlight the importance of gastrointestinal symptoms with respect to the patients' responses towards medical treatments and discuss the various possible adverse interactions that can potentially occur, which are still poorly understood.
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Auffret M, Le Jeune F, Maurus A, Drapier S, Houvenaghel JF, Robert GH, Sauleau P, Vérin M. Apomorphine pump in advanced Parkinson's disease: Effects on motor and nonmotor symptoms with brain metabolism correlations. J Neurol Sci 2016; 372:279-287. [PMID: 28017228 DOI: 10.1016/j.jns.2016.11.080] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Patients with advanced Parkinson's disease (PD) and contraindications for subthalamic nucleus deep brain stimulation (DBS) could particularly benefit from subcutaneous infusion therapy with apomorphine. This original study was designed to evaluate the general efficacy of add-on apomorphine in motor and nonmotor symptoms in advanced PD, while characterizing the changes induced in brain glucose metabolism. The aim was to look at the underlying anatomical-functional pathways. METHODS 12 patients with advanced PD were assessed before and after 6months of add-on apomorphine, using resting-state 18F-fluorodeoxyglucose positron emission tomography and exhaustive clinical assessments. RESULTS After 6months of therapy, oral treatment was significantly reduced. Both motor and nonmotor scores improved, with a beneficial effect on executive functions, quality of life and apathy. Significant metabolic changes were observed, with overall increases in the right fusiform gyrus and hippocampus, alongside a decrease in the left middle frontal gyrus. Consistent correlations between significant changes in clinical scores and metabolism were established. CONCLUSION Well tolerated, add-on apomorphine appears to be an interesting option for patients with fluctuations and contra-indications for DBS. Changes in brain metabolism, with beneficial effects on motor and nonmotor symptoms were observed after 6months. These preliminary results have to be confirmed by further studies.
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Affiliation(s)
- Manon Auffret
- Behavior and Basal Ganglia research unit (EA 4712), University of Rennes 1, Rennes, France.
| | - Florence Le Jeune
- Behavior and Basal Ganglia research unit (EA 4712), University of Rennes 1, Rennes, France; Nuclear Medicine Unit, Oncology Department Eugène Marquis Center, Rennes, France.
| | - Anne Maurus
- Behavior and Basal Ganglia research unit (EA 4712), University of Rennes 1, Rennes, France; Movement Disorders Unit, Neurology Department, Pontchaillou University Hospital, Rennes, France.
| | - Sophie Drapier
- Behavior and Basal Ganglia research unit (EA 4712), University of Rennes 1, Rennes, France; Movement Disorders Unit, Neurology Department, Pontchaillou University Hospital, Rennes, France.
| | - Jean-François Houvenaghel
- Behavior and Basal Ganglia research unit (EA 4712), University of Rennes 1, Rennes, France; Movement Disorders Unit, Neurology Department, Pontchaillou University Hospital, Rennes, France.
| | - Gabriel Hadrien Robert
- Behavior and Basal Ganglia research unit (EA 4712), University of Rennes 1, Rennes, France; Academic Department of Psychiatry, Guillaume Régnier Hospital, Rennes, France.
| | - Paul Sauleau
- Behavior and Basal Ganglia research unit (EA 4712), University of Rennes 1, Rennes, France; Neurophysiology Unit, Neurology Department, Rennes University Hospital, France.
| | - Marc Vérin
- Behavior and Basal Ganglia research unit (EA 4712), University of Rennes 1, Rennes, France; Movement Disorders Unit, Neurology Department, Pontchaillou University Hospital, Rennes, France.
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The efficacy of apomorphine – A non-motor perspective. Parkinsonism Relat Disord 2016; 33 Suppl 1:S28-S35. [DOI: 10.1016/j.parkreldis.2016.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/25/2016] [Accepted: 11/30/2016] [Indexed: 01/09/2023]
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Titova N, Chaudhuri KR. Apomorphine therapy in Parkinson's disease and future directions. Parkinsonism Relat Disord 2016; 33 Suppl 1:S56-S60. [DOI: 10.1016/j.parkreldis.2016.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 11/17/2016] [Accepted: 11/22/2016] [Indexed: 10/20/2022]
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Non-oral dopaminergic therapies for Parkinson's disease: current treatments and the future. NPJ PARKINSONS DISEASE 2016; 2:16023. [PMID: 28725704 PMCID: PMC5516582 DOI: 10.1038/npjparkd.2016.23] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 07/07/2016] [Accepted: 08/25/2016] [Indexed: 12/30/2022]
Abstract
Dysfunction of the gastrointestinal tract has now been recognized to affect all stages of Parkinson’s disease (PD). The consequences lead to problems with absorption of oral medication, erratic treatment response, as well as silent aspiration, which is one of the key risk factors in developing pneumonia. The issue is further complicated by other gut abnormalities, such as small intestinal bacterial overgrowth (SIBO) and an altered gut microbiota, which occur in PD with variable frequency. Clinically, these gastrointestinal abnormalities might be associated with symptoms such as nausea, early-morning “off”, and frequent motor and non-motor fluctuations. Therefore, non-oral therapies that avoid the gastrointestinal system seem a rational option to overcome the problems of oral therapies in PD. Hence, several non-oral strategies have now been actively investigated and developed. The transdermal rotigotine patch, infusion therapies with apomorphine, intrajejunal levodopa, and the apomorphine pen strategy are currently in clinical use with a few others in development. In this review, we discuss and summarize the most recent developments in this field with a focus on non-oral dopaminergic strategies (excluding surgical interventions such as deep brain stimulation) in development or to be licensed for management of PD.
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Stocchi F, Torti M, Fossati C. Advances in dopamine receptor agonists for the treatment of Parkinson's disease. Expert Opin Pharmacother 2016; 17:1889-902. [PMID: 27561098 DOI: 10.1080/14656566.2016.1219337] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Dopamine agonists (DA) are a class of agents which directly stimulate dopamine receptors mimicking the endogenous neurotransmitter dopamine. At first used as adjunctive therapy in the advanced phases of the disease, over the years a significant role was found for DA monotherapy as a first approach in the initial stage of Parkinson's disease (PD). Several reviews have already reported efficacy and safety of DA in PD and differences between DA and levodopa. Therefore the objective of this review is to gather recent updates in DA therapy. A thorough knowledge of recent literature evidences, would help clinician in the management of treatment with DA. AREAS COVERED Our review investigates recent updates on DA therapy, the role of these compounds in controlling non-motor symptoms (NMS) as well as new formulations under clinical evaluation and newly emerged post-marketing safety considerations. A literature search has been performed using Medline and reviewing the bibliographies of selected articles. EXPERT OPINION DA represents a very important option in the treatment of PD, even though there are still some criticisms and unmet needs. A better knowledge of dopamine receptors could lead to identification of new compounds able to better balance clinical efficacy and side effects.
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Affiliation(s)
- Fabrizio Stocchi
- a Department of Neurology, Institute for research and medical care , IRCCS San Raffaele Roma , Roma , Italy
| | - Margherita Torti
- a Department of Neurology, Institute for research and medical care , IRCCS San Raffaele Roma , Roma , Italy
| | - Chiara Fossati
- a Department of Neurology, Institute for research and medical care , IRCCS San Raffaele Roma , Roma , Italy
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Martínez-Fernández R, Schmitt E, Martinez-Martin P, Krack P. The hidden sister of motor fluctuations in Parkinson's disease: A review on nonmotor fluctuations. Mov Disord 2016; 31:1080-94. [PMID: 27431515 DOI: 10.1002/mds.26731] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 06/13/2016] [Accepted: 06/19/2016] [Indexed: 12/29/2022] Open
Abstract
Only a few years after the introduction of levodopa, the first descriptions of motor fluctuations and dyskinesia related to dopaminergic therapy appeared. In PD, attention turned to their management, that had dampened the euphoria of the "levodopa miracle." It soon became clear that neuropsychiatric, autonomic, and sensory features also tend to develop fluctuations after chronic exposure to l-dopa. The diversity of fluctuating nonmotor symptoms, their largely subjective nature, coupled with a frequent lack of insight led to difficulties in identification and quantification. This may explain why, despite the high impact of nonmotor symptoms on patient autonomy and quality of life, evaluation of nonmotor fluctuations is not part of clinical routine. In view of the lack of specific validated assessment tools, detailed anamnesis should ideally be coupled with an evaluation in both ON and OFF drug conditions. The mechanisms of nonmotor fluctuations are not well understood. It is thought that they share dopaminergic presynaptic pharmacokinetic and postsynaptic pharmacodynamic mechanisms with the classical motor complications, but involve different neural pathways. Although symptoms fluctuate with dopaminergic treatment, serotonine and norepinephrine denervation, as well as interactions between neurotransmitter systems, probably contribute to their diversity. The lack of validated tools for assessment of these phenomena explains the almost complete absence of treatment studies. Management, largely resulting from expert opinion, includes psychiatric follow-up, nondopaminergic drugs, and advanced dopaminergic treatment, including drug delivery pumps and DBS. This review aims to provide a starting point for the understanding, diagnosis, and management of nonmotor fluctuations. © 2016 International Parkinson and Movement Disorder Society.
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Affiliation(s)
| | - Emmanuelle Schmitt
- Movement Disorders Unit, Department of Psychiatry and Neurology, CHU de Grenoble, Université de Grenoble Alpes and Grenoble Institut des Neurosciences, INSERM U386, Grenoble, France
| | - Pablo Martinez-Martin
- National Center of Epidemiology, Carlos III Institute of Health and CIBERNED, Madrid, Spain
| | - Paul Krack
- Neurology Division, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
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Borgemeester RWK, Lees AJ, van Laar T. Parkinson's disease, visual hallucinations and apomorphine: A review of the available evidence. Parkinsonism Relat Disord 2016; 27:35-40. [PMID: 27132157 DOI: 10.1016/j.parkreldis.2016.04.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 04/19/2016] [Accepted: 04/21/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND Visual hallucinations (VH) occur in the clinical course of Parkinson's disease (PD) and are predictive for PD dementia. The genesis of VH is related to impaired bottom-up and/or top-down visual processing which can be linked to cholinergic dysfunction and mono-amine imbalance. The risk of developing VH with oral dopamine agonists seems to increase with advancing disease, while in contrast some clinical studies suggest that apomorphine does not worsen VH, or might even improve VH. METHODS The aim of this study is to review the current evidence of apomorphine and its effects on VH in PD patients. RESULTS Apomorphine is well-tolerated in PD patients with VH, also in long-term follow-up studies. Apomorphine is also suggested to have the potential to alleviate VH. Some data suggest that the positive effect of apomorphine on VH is related to its piperidine moiety, part of many anti-psychotics. Irrespective this piperidine moiety, apomorphine has a high D1-like receptor affinity, and acts as a serotonin 5-HT2A receptor antagonist, which might explain the potential anti-hallucinogenic properties as well. CONCLUSION The anecdotal evidence suggesting that apomorphine has a relatively low proclivity to induce VH in PD may be due to its capacity to reduce serotonergic activity in particular. Therefore apomorphine is still an option to consider in fluctuating PD patients with VH, if they are treated properly with respect to their cholinergic deficits and existing VH.
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Affiliation(s)
- Robbert W K Borgemeester
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Andrew J Lees
- Reta Lila Weston Institute of Neurological Studies, UCL Institute of Neurology, London, UK
| | - Teus van Laar
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Băjenaru O, Ene A, Popescu BO, Szász JA, Sabău M, Mureşan DF, Perju-Dumbrava L, Popescu CD, Constantinescu A, Buraga I, Simu M. The effect of levodopa-carbidopa intestinal gel infusion long-term therapy on motor complications in advanced Parkinson's disease: a multicenter Romanian experience. J Neural Transm (Vienna) 2015; 123:407-14. [PMID: 26699635 PMCID: PMC4805768 DOI: 10.1007/s00702-015-1496-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 12/02/2015] [Indexed: 11/23/2022]
Abstract
Chronic treatment with oral levodopa is associated with an increased frequency of motor complications in the late stages of Parkinson’s disease (PD). Continuous administration of levodopa–carbidopa intestinal gel (LCIG—Duodopa®, Abbott Laboratories), which has been available in Romania since 2009, represents an option for treating patients with advanced PD. Our primary objective was to report changes in motor complications after initiation of LCIG therapy. The secondary objectives were as follows: to determine the impact of LCIG therapy on the daily levodopa dose variation before/and after LCIG, to collect patient self-assessments of quality of life (QoL), and to study the overall tolerability and safety of LCIG administration. A retrospective analysis (2009–2013) of LCIG therapy and the experience in nine neurology centers in Romania was performed. The impact of LCIG therapy was evaluated by analyzing changes in motor fluctuations, dyskinesia and the patients’ QoL after initiating therapy. The safety of LCIG therapy was estimated by noting agent-related adverse events (AEs) and medical device-related AEs. In the 113 patients included, we observed a significant improvement in PD symptoms after initiation of LCIG therapy. The “on” period increased, with a mean value of 6.14 h, and the dyskinesia period was reduced, with a mean value of 29.4 %. The quantified non-motor symptoms subsided. The patients exhibited significant improvements in QoL scores. There were few AEs and few cases of LCIG therapy discontinuation. LCIG is an important and available therapeutic option for managing patients with advanced PD.
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Affiliation(s)
- O Băjenaru
- Department of Neurology, University of Medicine and Pharmacy "Carol Davila" Bucharest, University Emergency Hospital Bucharest, 169 Splaiul Independentei, Sector 5, Bucharest, Romania
| | - A Ene
- Department of Neurology, University of Medicine and Pharmacy "Carol Davila" Bucharest, University Emergency Hospital Bucharest, 169 Splaiul Independentei, Sector 5, Bucharest, Romania
| | - B O Popescu
- Department of Neurology, University of Medicine and Pharmacy "Carol Davila" Bucharest, Colentina Hospital, 19-21 Stefan cel Mare Street, Sector 2, 020125, Bucharest, Romania
| | - J A Szász
- Department of Neurology, University of Medicine and Pharmacy Targu Mures, 38 Gh Marinescu Street, 540139, Targu Mures, Mures, Romania
| | - M Sabău
- Department of Neurology, Emergency Clinical Hospital Oradea, 65 Gh Doja Street, 410169, Oradea, Bihor, Romania
| | - D F Mureşan
- Department of Neurology, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj Napoca, Cluj County Hospital, 3-5 Clinicilor Street, 400006, Cluj-Napoca, Romania
| | - L Perju-Dumbrava
- Department of Neurology, University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj Napoca, Cluj County Hospital, 3-5 Clinicilor Street, 400006, Cluj-Napoca, Romania
| | - C D Popescu
- Neurology Rehabilitation Department, University of Medicine and Pharmacy "Gr. T. Popa" Iasi, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661, Iasi, Romania
| | - A Constantinescu
- Neurology Rehabilitation Department, University of Medicine and Pharmacy "Gr. T. Popa" Iasi, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661, Iasi, Romania
| | - I Buraga
- Department of Neurology, University of Medicine and Pharmacy "Carol Davila" Bucharest, Colentina Hospital, 19-21 Stefan cel Mare Street, Sector 2, 020125, Bucharest, Romania
| | - M Simu
- Department of Neurology, University of Medicine and Pharmacy "Victor Babes," Timisoara County Hospital, 10 Iosif Bulbuca Street, 300736, Timisoara, Timis, Romania.
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Trenkwalder C, Chaudhuri KR, García Ruiz PJ, LeWitt P, Katzenschlager R, Sixel-Döring F, Henriksen T, Sesar Á, Poewe W, Baker M, Ceballos-Baumann A, Deuschl G, Drapier S, Ebersbach G, Evans A, Fernandez H, Isaacson S, van Laar T, Lees A, Lewis S, Martínez Castrillo JC, Martinez-Martin P, Odin P, O'Sullivan J, Tagaris G, Wenzel K. Expert Consensus Group report on the use of apomorphine in the treatment of Parkinson's disease--Clinical practice recommendations. Parkinsonism Relat Disord 2015; 21:1023-30. [PMID: 26189414 DOI: 10.1016/j.parkreldis.2015.06.012] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 05/15/2015] [Accepted: 06/13/2015] [Indexed: 12/16/2022]
Abstract
Extensive published evidence supports the use of subcutaneously-administered apomorphine as an effective therapy for Parkinson's disease (PD) but to date no consensus recommendations have been available to guide healthcare professionals in the optimal application of apomorphine therapy in clinical practice. This document outlines best-practice recommendations for selecting appropriate candidates for apomorphine intermittent injection (the pen-injection formulation) or apomorphine continuous infusion (the pump formulation), for initiating patients onto therapy and for managing their ongoing treatment. Apomorphine is a suitable therapeutic option for PD patients who experience troublesome 'off' periods despite optimized treatment with oral PD medications. Due to its speed of onset, apomorphine injection is particularly suited to those patients requiring rapid, reliable relief of both unpredictable and predictable 'off' periods, those who require reliable and fast relief when anticipating an 'off', those with levodopa absorption or gastric emptying problems resulting in delayed or failed 'on', or for rapid relief of early morning dystonia or akinesia. Apomorphine infusion(1) is suited for patients whose 'off' periods can no longer be adequately controlled by standard oral PD treatment or for those in whom rescue doses of apomorphine injection are effective but either needed too frequently (more than 4-6 times per day), or are associated with increasing dyskinesia. In addition to treating motor fluctuations, there is evidence that apomorphine infusion may be effective for the management of specific non-motor symptoms of PD associated with 'off' periods. Apomorphine infusion is less invasive than other non-oral treatment options for advancing disease, intrajejunal levodopa infusion and deep-brain stimulation.
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Affiliation(s)
- Claudia Trenkwalder
- Centre of Parkinsonism and Movement Disorders, Paracelsus-Elena Hospital, Kassel, Germany; Department of Neurosurgery, University Medical Centre, Goettingen, Germany.
| | - K Ray Chaudhuri
- National Parkinson Foundation Centre of Excellence, Kings College Hospital, Denmark Hill Campus, London, UK
| | - Pedro J García Ruiz
- Movement Disorders Unit, Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain
| | - Peter LeWitt
- Wayne State University School of Medicine, Parkinson's Disease and Movement Disorders Program, Henry Ford West Bloomfield Hospital, West Bloomfield, MI, USA
| | - Regina Katzenschlager
- Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Danube Hospital, Vienna, Austria
| | - Friederike Sixel-Döring
- Centre of Parkinsonism and Movement Disorders, Paracelsus-Elena Hospital, Kassel, Germany; Department of Neurology, Philipps-University, Marburg, Germany
| | - Tove Henriksen
- Movement Disorder Clinic, Bispebjerg Hospital, Copenhagen, Denmark
| | - Ángel Sesar
- Department of Neurology, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Austria
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Van der Schyf CJ. Rational drug discovery design approaches for treating Parkinson’s disease. Expert Opin Drug Discov 2015; 10:713-41. [DOI: 10.1517/17460441.2015.1041495] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Unti E, Ceravolo R, Bonuccelli U. Apomorphine hydrochloride for the treatment of Parkinson’s disease. Expert Rev Neurother 2015; 15:723-32. [DOI: 10.1586/14737175.2015.1051468] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
Current research shows that apomorphine is an effective treatment for symptoms of Parkinson's Disease (PD). The highly lipophilic structure allows apomorphine to cross cell membranes rapidly, leading to the rapid onset of action for on/off symptoms of PD. The use of apomorphine was limited in the past due to peripheral side effects, but with the advent of better delivery systems and medications to control side effects, apomorphine is better tolerated and more widely in use. The major delivery systems are continuous subcutaneous infusions and intermittent subcutaneous injections, but other delivery routes are under investigation. The purpose of this article is to discuss the current use of apomorphine, the current delivery systems and to discuss future research.
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Affiliation(s)
- Allison Boyle
- University of Texas Health Science Center at Houston, 6410 Fannin Street, Ste 1010, Houston, TX, 77030, USA,
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Abstract
Non-motor symptoms are a key component of Parkinson's disease, possibly representing a clinical biomarker of its premotor phase. The burden of non-motor symptoms can define a patient's health-related quality of life. Non-motor symptoms substantially increase the cost of care-requiring increased hospitalisation and treatment-and pose a major challenge to healthcare professionals. However, clinicians often regard non-motor symptoms and their management as peripheral to that of the motor symptoms. Here, we address the clinical issues and unmet needs of non-motor symptoms in Parkinson's disease.
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Affiliation(s)
- Antoniya Todorova
- Department of Neurology, National Parkinson Foundation Centre of Excellence, King's College Hospital, and Kings College, London, UK
| | - Peter Jenner
- Institute of Pharmaceutical Science, King's College London, London, UK
| | - K Ray Chaudhuri
- Department of Neurology, National Parkinson Foundation Centre of Excellence, King's College Hospital, and Kings College, London, UK
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Wenzel K, Homann CN, Fabbrini G, Colosimo C. The role of subcutaneous infusion of apomorphine in Parkinson’s disease. Expert Rev Neurother 2014; 14:833-43. [DOI: 10.1586/14737175.2014.928202] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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