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Sringean J, Udomsirithamrong O, Bhidayasiri R. Too little or too much nocturnal movements in Parkinson's disease: A practical guide to managing the unseen. Clin Park Relat Disord 2024; 10:100258. [PMID: 38845753 PMCID: PMC11153921 DOI: 10.1016/j.prdoa.2024.100258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/13/2024] [Accepted: 05/21/2024] [Indexed: 06/09/2024] Open
Abstract
Nocturnal and sleep-related motor disorders in people with Parkinson's disease (PD) have a wide spectrum of manifestations and present a complex clinical picture. Problems can arise due to impaired movement ability (hypokinesias), e.g. nocturnal hypokinesia or early-morning akinesia, or to excessive movement (hyperkinesias), e.g. end-of-the-day dyskinesia, parasomnias, periodic limb movement during sleep and restless legs syndrome. These disorders can have a significant negative impact on the sleep, daytime functional ability, and overall quality of life of individuals with PD and their carers. The debilitating motor issues are often accompanied by a combination of non-motor symptoms, including pain and cramping, which add to the overall burden. Importantly, nocturnal motor disorders encompass a broader timeline than just the period of sleep, often starting in the evening, as well as occurring throughout the night and on awakening, and are not just limited to problems of insomnia or sleep fragmentation. Diagnosis can be challenging as, in many cases, the 'gold standard' assessment method is video polysomnography, which may not be available in all settings. Various validated questionnaires are available to support evaluation, and alternative approaches, using wearable sensors and digital technology, are now being developed to facilitate early diagnosis and monitoring. This review sets out the parameters of what can be considered normal nocturnal movement and describes the clinical manifestations, usual clinical or objective assessment methods, and evidence for optimal management strategies for the common nocturnal motor disorders that neurologists will encounter in people with PD in their clinical practice.
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Affiliation(s)
- Jirada Sringean
- Chulalongkorn Centre of Excellence for Parkinson’s Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Ornanong Udomsirithamrong
- Chulalongkorn Centre of Excellence for Parkinson’s Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson’s Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
- The Academy of Science, The Royal Society of Thailand, Bangkok 10330, Thailand
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2
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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 2024:106079. [PMID: 38503575 DOI: 10.1016/j.parkreldis.2024.106079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [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.
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3
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Foltynie T, Bruno V, Fox S, Kühn AA, Lindop F, Lees AJ. Medical, surgical, and physical treatments for Parkinson's disease. Lancet 2024; 403:305-324. [PMID: 38245250 DOI: 10.1016/s0140-6736(23)01429-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 05/09/2023] [Accepted: 07/06/2023] [Indexed: 01/22/2024]
Abstract
Although dopamine replacement therapy remains a core component of Parkinson's disease treatment, the onset of motor fluctuations and dyskinetic movements might require a range of medical and surgical approaches from a multidisciplinary team, and important new approaches in the delivery of dopamine replacement are becoming available. The more challenging, wide range of non-motor symptoms can also have a major impact on the quality of life of a patient with Parkinson's disease, and requires careful multidisciplinary management using evidence-based knowledge, as well as appropriately tailored strategies according to the individual patient's needs. Disease-modifying therapies are urgently needed to prevent the development of the most disabling refractory symptoms, including gait and balance difficulties, cognitive impairment and dementia, and speech and swallowing impairments. In the third paper in this Series, we present the latest evidence supporting the optimal treatment of Parkinson's disease, and describe an expert approach to many aspects of treatment choice where an evidence base is insufficient.
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Affiliation(s)
- Tom Foltynie
- Department of Clinical and Movement Neurosciences, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK.
| | - Veronica Bruno
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Susan Fox
- Edmond J Safra Program in Parkinson Disease, Krembil Brain Institute, Toronto Western Hospital, Toronto, ON, Canada; Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Andrea A Kühn
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany; NeuroCure Cluster of Excellence, Charité-Universitätsmedizin Berlin, Berlin, Germany; Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fiona Lindop
- University Hospitals of Derby and Burton NHS Foundation Trust, Specialist Rehabilitation, Florence Nightingale Community Hospital, Derby, UK
| | - Andrew J Lees
- Department of Clinical and Movement Neurosciences, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK; Reta Lila Weston Institute of Neurological Studies, University College London, London, UK
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4
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Koch J. Management of OFF condition in Parkinson disease. Ment Health Clin 2023; 13:289-297. [PMID: 38058599 PMCID: PMC10696172 DOI: 10.9740/mhc.2023.12.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 08/31/2023] [Indexed: 12/08/2023] Open
Abstract
Parkinson disease (PD) impacts nearly 1 million individuals in the United States. Nearly every patient with PD will require therapy with dopamine in the form of levodopa as the disease progresses. In more advanced stages of the disease, patients will experience motor fluctuations and require adjustment to their medication regimens to maintain good control of their symptoms. During the last 10 years, several new therapeutic treatment options have come to the market to treat motor fluctuations and improve patient quality of life. Some of these agents represent additional options to previously available drug classes, such as the catechol-O-methyl transferase (COMT) inhibitor, opicapone, and monoamine-oxidase B-inhibitor (MAO-B inhibitor), safinamide, as well as new dosage forms for available therapeutics. One new agent, istradefylline, has a novel mechanism in the treatment of PD. The place in therapy for these newer therapeutic options will be explored through a series of patient cases. This article focuses on evidence-based recommendations for the use of these newer options in the management of patients experiencing OFF episodes.
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5
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Isaacson SH, Kremens D, Torres-Yaghi Y, Stocchi F, Antonini A. Importance of time to ON versus wearing OFF in total daily OFF time experienced by patients with Parkinson's disease. Parkinsonism Relat Disord 2023; 114:105495. [PMID: 37517986 DOI: 10.1016/j.parkreldis.2023.105495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 08/01/2023]
Abstract
Most patients with Parkinson's disease (PD) receiving levodopa (LD)/DOPA decarboxylase inhibitors develop motor fluctuations with an increasing amount of OFF time, negatively impacting patient quality of life. Herein, we review the evidence supporting the substantial, yet underappreciated contribution of delays in time to ON (including delayed ON and no ON) to total daily OFF time. Most clinical studies use patient diaries that do not capture time to ON and wearing OFF separately as related to LD dosing, and consequently, most OFF time has generally been attributed to wearing OFF. Hence, most treatment regimens focus on reducing wearing OFF by changing LD dosing/formulations and/or using "ON-extenders" (eg, catechol-o-methyltransferase inhibitors, monoamine oxidase-B inhibitors, extended-release amantadine, and adenosine A2A receptor antagonists). However, the literature describing approved treatments for PD that has focused on delays in time to ON is sparse and suggests this type of OFF may comprise more than twice the amount of total daily OFF time as wearing OFF. Here, we advocate for the importance of measuring and adequately addressing delays in time to ON and build support for the consistent inclusion of the time to ON measurement in future clinical trials.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, 951 NW 13th St, Bldg. 5-E, Boca Raton, FL, 33486, USA.
| | - Daniel Kremens
- Department of Neurology, Thomas Jefferson University, 901 Walnut Street, Suite 400, Philadelphia, PA, 19107, USA.
| | - Yasar Torres-Yaghi
- Department of Neurology, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, 7th Floor, PHC Building, Washington, DC, 20007, USA.
| | - Fabrizio Stocchi
- University San Raffaele Rome and Institute for Research and Medical Care IRCCS San Raffaele Pisana, Rome, Italy.
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Study Center on Neurodegeneration (CESNE), University of Padua, Padua, Italy.
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6
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Sparrow D, DeMolles D, Dubaz O, Durso R, Rosner B. Design issues in crossover trials involving patients with Parkinson's disease. Front Neurol 2023; 14:1197281. [PMID: 37670777 PMCID: PMC10476358 DOI: 10.3389/fneur.2023.1197281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/05/2023] [Indexed: 09/07/2023] Open
Abstract
Background and objectives Crossover designs are frequently used to assess treatments for patients with Parkinson's disease. Typically, two-period two-treatment trials include a washout period between the 2 periods and assume that the washout period is sufficiently long to eliminate carryover effects. A complementary strategy might be to jointly model carryover and treatment effects, though this has rarely been done in Parkinson's disease crossover studies. The primary objective of this research is to demonstrate a modeling approach that assesses treatment and carryover effects in one unified mixed model analysis and to examine how it performs in a simulation study and a real data analysis example, as compared to other data analytic approaches used in Parkinson's disease crossover studies. Methods We examined how three different methods of analysis (standard crossover t-test, mixed model with a carryover term included in model statement, and mixed model with no carryover term) performed in a simulation study and illustrated the methods in a real data example in Parkinson's disease. Results The simulation study based on the presence of a carryover effect indicated that mixed models with a carryover term and an unstructured correlation matrix provided unbiased estimates of treatment effect and appropriate type I error. The methods are illustrated in a real data example involving Parkinson's disease. Our literature review revealed that a majority of crossover studies included a washout period but did not assess whether the washout was sufficiently long to eliminate the possibility of carryover. Discussion We recommend using a mixed model with a carryover term and an unstructured correlation matrix to obtain unbiased estimates of treatment effect.
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Affiliation(s)
- David Sparrow
- VA Boston Healthcare System, Boston, MA, United States
- Departments of Medicine and Public Health, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | | | - Ornella Dubaz
- VA Boston Healthcare System, Boston, MA, United States
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Raymon Durso
- Departments of Medicine and Public Health, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Bernard Rosner
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, United States
- Channing Division for Network Medicine, Brigham and Women’s Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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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.
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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
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8
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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.
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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
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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.
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10
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Isaacson SH, Bowling A, Zhang I, Pappert E, Stocchi F. Motor response with apomorphine sublingual film and levodopa in patients with OFF episodes. Neurodegener Dis Manag 2022; 13:75-84. [PMID: 36562349 DOI: 10.2217/nmt-2022-0038] [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: 12/24/2022] Open
Abstract
Aim: Evaluate timing of motor improvement with carbidopa/levodopa (CD/LD) and apomorphine sublingual film (SL-APO) in patients with Parkinson's disease and OFF episodes. Methods: A post hoc pooled analysis from two studies assessed Movement Disorder Society Unified Parkinson's Disease Rating Scale Part III (MDS-UPDRS-III) scores and investigator-rated FULL ON. Results: At 15 and 30 min following the prescribed first daily CD/LD dose, mean improvements in MDS-UPDRS-III scores were -6.7 and -16.3, respectively, and FULL ON was achieved by 6.5 and 41.8% of patients. Following an optimized SL-APO dose, mean improvements in MDS-UPDRS-III scores were -13.9 and -22.9, and FULL ON was achieved by 34.7 and 81.0% of patients. Conclusion: Concomitant administration of SL-APO with carbidopa/levodopa may be useful for delayed ON.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease & Movement Disorders Center of Boca Raton, Boca Raton, FL 33486, USA
| | - Alyssa Bowling
- Sunovion Pharmaceuticals Inc., Marlborough, MA 01752, USA
| | - Ian Zhang
- Sunovion Pharmaceuticals Inc., Marlborough, MA 01752, USA
| | - Eric Pappert
- Sunovion Pharmaceuticals Inc., Marlborough, MA 01752, USA
| | - Fabrizio Stocchi
- Department of Neurology, University & Institute for Research and Medical Care, IRCCS San Raffaele Pisana, Rome, 00163, Italy
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Nimmons D, Bhanu C, Orlu M, Schrag A, Walters K. Orthostatic Hypotension and Antiparkinsonian Drugs: A Systematic Review and Meta-analysis. J Geriatr Psychiatry Neurol 2022; 35:639-654. [PMID: 34964392 PMCID: PMC9386765 DOI: 10.1177/08919887211060017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Orthostatic hypotension (OH) is multifactorial in Parkinson's disease (PD). Antiparkinsonian medication can contribute to OH, leading to increased risk of falls, weakness and fatigue. METHODS We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of antiparkinsonian drugs associated with OH as an adverse effect, compared to placebo. We searched EMBASE, MEDLINE and Web of Science databases until November 2020. Analysis used fixed-effects models and the GRADE tool to rate quality of evidence. Meta-analysis was performed if 3 or more studies of a drug group were available. RESULTS Twenty-one RCTs including 3783 patients were included comparing 6 PD drug groups to placebo (MAO-B inhibitors, dopamine agonists, levodopa, COMT inhibitors, levodopa and adenosine receptor antagonists). OH was recorded as an adverse event or measurement of vital signs, without further specification on how this was defined or operationalised. Meta-analysis was performed for MAO-B inhibitors and dopamine agonists, as there were 3 or more studies for these drug groups. In this analysis, compared with placebo, neither MAO-B inhibitors or dopamine agonists were associated with increased risk of OH, (OR 2.28 [95% CI:0.81-6.46]), (OR 1.39 [95% CI:0.97-1.98]). CONCLUSIONS Most studies did not specifically report OH, or reporting of OH was limited, including how and when it was measured. Furthermore, studies specifically reporting OH included participants that were younger than typical PD populations without multimorbidity. Future trials should address this, for example,, by including individuals over the age of 75, to improve estimations of how antiparkinsonian medications affect risk of OH.
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Affiliation(s)
- Danielle Nimmons
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK,Danielle Nimmons, Research Department of Primary Care and Population Health, UCL, Rowland Hill Street, London NW3 2PF, UK.
| | - Cini Bhanu
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK
| | | | - Anette Schrag
- Department of Neurology, Institute of Neurology, UCL, UK
| | - Kate Walters
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, UCL, UK
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12
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Sringean J, Thanawattano C, Bhidayasiri R. Technological evaluation of strategies to get out of bed by people with Parkinson's disease: Insights from multisite wearable sensors. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:922218. [PMID: 36090600 PMCID: PMC9453393 DOI: 10.3389/fmedt.2022.922218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 08/01/2022] [Indexed: 12/02/2022] Open
Abstract
Background Difficulty getting out of bed is a common night-time and early morning manifestation of Parkinson's disease (PD), rated by 40% of the patients as their most concerning motor symptoms. However, current assessment methods are based on clinical interviews, video analysis, and clinical scales as objective outcome measures are not yet available. Objective To study the technical feasibility of multisite wearable sensors in the assessment of the supine-to-stand (STS) task as a determinant of the ability to get out of bed in patients with PD and age-matched control subjects, and develop relevant objective outcome measures. Methods The STS task was assessed in 32 patients with PD (mean Hoehn and Yahr; HY = 2.5) in the early morning before their first dopaminergic medication, and in 14 control subjects, using multisite wearable sensors (NIGHT-Recorder®; trunk, both wrists, and both ankles) in a sleep laboratory. Objective getting out of bed parameters included duration, onset, velocity and acceleration of truncal rotation, and angle deviation (a°) from the z-axis when subjects rose from the bed at different angles from the x-axis (10°, 15°, 30°, 45°, and 60°) as measures of truncal lateral flexion. Movement patterns were identified from the first body part or parts that moved. Correlation analysis was performed between these objective outcomes and standard clinical rating scales. Results Compared to control subjects, the duration of STS was significantly longer in patients with PD (p = 0.012), which is associated with a significantly slower velocity of truncal rotation (p = 0.003). Moderate and significant correlations were observed between the mean STS duration and age, and the Nocturnal Hypokinesia Questionnaire. The velocity of truncal rotation negatively and significantly correlated with HY staging. Any arm and leg moved together as the first movement significantly correlated with UPDRS-Axial and item #28. Several other correlations were also observed. Conclusion Our study was able to demonstrate the technical feasibility of using multisite wearable sensors to quantitatively assess early objective outcome measures of the ability of patients with PD to get out of bed, which significantly correlated with axial severity scores, suggesting that axial impairment could be a contributing factor in difficulty getting out of bed. Future studies are needed to refine these outcome measures for use in therapeutic trials related to nocturia or early morning akinesia in PD.
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Affiliation(s)
- Jirada Sringean
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Chusak Thanawattano
- National Science and Technology Development Agency (NSTDA), Pathumthani, Thailand
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- The Academy of Science, The Royal Society of Thailand, Bangkok, Thailand
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13
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High-dose versus low-dose inhaled levodopa (CVT-301) in patients with Parkinson disease for the treatment of OFF episodes: a meta-analysis of randomized controlled trials. Neurol Sci 2022; 43:6233-6241. [DOI: 10.1007/s10072-022-06298-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 07/22/2022] [Indexed: 10/16/2022]
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Di Luca DG, Reyes NGD, Fox SH. Newly Approved and Investigational Drugs for Motor Symptom Control in Parkinson's Disease. Drugs 2022; 82:1027-1053. [PMID: 35841520 PMCID: PMC9287529 DOI: 10.1007/s40265-022-01747-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 12/11/2022]
Abstract
Motor symptoms are a core feature of Parkinson’s disease (PD) and cause a significant burden on patients’ quality of life. Oral levodopa is still the most effective treatment, however, the motor benefits are countered by inherent pharmacologic limitations of the drug. Additionally, with disease progression, chronic levodopa leads to the appearance of motor complications including motor fluctuations and dyskinesia. Furthermore, several motor abnormalities of posture, balance, and gait may become less responsive to levodopa. With these unmet needs and our evolving understanding of the neuroanatomic and pathophysiologic underpinnings of PD, several advances have been made in defining new therapies for motor symptoms. These include newer levodopa formulations and drug delivery systems, refinements in adjunctive medications, and non-dopaminergic treatment strategies. Although some are in early stages of development, these novel treatments potentially widen the available options for the management of motor symptoms allowing clinicians to provide an individually tailored care for PD patients. Here, we review the existing and emerging interventions for PD with focus on newly approved and investigational drugs for motor symptoms, motor fluctuations, dyskinesia, and balance and gait dysfunction.
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Affiliation(s)
- Daniel Garbin Di Luca
- Edmond J. Safra Program in Parkinson's Disease, Movement Disorders Clinic, Krembil Brain Institute, Toronto Western Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Nikolai Gil D Reyes
- Edmond J. Safra Program in Parkinson's Disease, Movement Disorders Clinic, Krembil Brain Institute, Toronto Western Hospital, Toronto, ON, Canada
| | - Susan H Fox
- Edmond J. Safra Program in Parkinson's Disease, Movement Disorders Clinic, Krembil Brain Institute, Toronto Western Hospital, Toronto, ON, Canada.
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15
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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.
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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
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16
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Ye Y, Ma Y, Zhu J. The future of dry powder inhaled therapy: Promising or Discouraging for systemic disorders? Int J Pharm 2022; 614:121457. [PMID: 35026316 PMCID: PMC8744475 DOI: 10.1016/j.ijpharm.2022.121457] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/02/2022] [Accepted: 01/05/2022] [Indexed: 12/25/2022]
Abstract
Dry powder inhalation therapy has been shown to be an effective method for treating respiratory diseases like asthma, Chronic Obstructive Pulmonary Diseases and Cystic Fibrosis. It has also been widely accepted and used in clinical practices. Such success has led to great interest in inhaled therapy on treating systemic diseases in the past two decades. The current coronavirus (COVID-19) pandemic also has increased such interest and is triggering more potential applications of dry powder inhalation therapy in vaccines and antivirus drugs. Would the inhaled dry powder therapy on systemic disorders be as encouraging as expected? This paper reviews the marketed and in-development dry powder inhaler (DPI) products on the treatment of systemic diseases, their status in clinical trials, as well as the potential for COVID-19 treatment. The advancements and unmet problems on DPI systems are also summarized. With countless attempts behind and more challenges ahead, it is believed that the dry powder inhaled therapy for the treatment of systemic disorders still holds great potential and promise.
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Affiliation(s)
- Yuqing Ye
- University of Western Ontario, 1151 Richmond Street, London, N6A 3K7, Canada; Ningbo Inhale Pharma, 2260 Yongjiang Avenue, Ningbo National High-Tech Zone, Ningbo, 315000, China
| | - Ying Ma
- University of Western Ontario, 1151 Richmond Street, London, N6A 3K7, Canada; Ningbo Inhale Pharma, 2260 Yongjiang Avenue, Ningbo National High-Tech Zone, Ningbo, 315000, China
| | - Jesse Zhu
- University of Western Ontario, 1151 Richmond Street, London, N6A 3K7, Canada.
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17
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Anderson S, Atkins P, Bäckman P, Cipolla D, Clark A, Daviskas E, Disse B, Entcheva-Dimitrov P, Fuller R, Gonda I, Lundbäck H, Olsson B, Weers J. Inhaled Medicines: Past, Present, and Future. Pharmacol Rev 2022; 74:48-118. [PMID: 34987088 DOI: 10.1124/pharmrev.120.000108] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/06/2021] [Indexed: 12/21/2022] Open
Abstract
The purpose of this review is to summarize essential pharmacological, pharmaceutical, and clinical aspects in the field of orally inhaled therapies that may help scientists seeking to develop new products. After general comments on the rationale for inhaled therapies for respiratory disease, the focus is on products approved approximately over the last half a century. The organization of these sections reflects the key pharmacological categories. Products for asthma and chronic obstructive pulmonary disease include β -2 receptor agonists, muscarinic acetylcholine receptor antagonists, glucocorticosteroids, and cromones as well as their combinations. The antiviral and antibacterial inhaled products to treat respiratory tract infections are then presented. Two "mucoactive" products-dornase α and mannitol, which are both approved for patients with cystic fibrosis-are reviewed. These are followed by sections on inhaled prostacyclins for pulmonary arterial hypertension and the challenging field of aerosol surfactant inhalation delivery, especially for prematurely born infants on ventilation support. The approved products for systemic delivery via the lungs for diseases of the central nervous system and insulin for diabetes are also discussed. New technologies for drug delivery by inhalation are analyzed, with the emphasis on those that would likely yield significant improvements over the technologies in current use or would expand the range of drugs and diseases treatable by this route of administration. SIGNIFICANCE STATEMENT: This review of the key aspects of approved orally inhaled drug products for a variety of respiratory diseases and for systemic administration should be helpful in making judicious decisions about the development of new or improved inhaled drugs. These aspects include the choices of the active ingredients, formulations, delivery systems suitable for the target patient populations, and, to some extent, meaningful safety and efficacy endpoints in clinical trials.
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Affiliation(s)
- Sandra Anderson
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Paul Atkins
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Per Bäckman
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - David Cipolla
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Andrew Clark
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Evangelia Daviskas
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Bernd Disse
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Plamena Entcheva-Dimitrov
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Rick Fuller
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Igor Gonda
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Hans Lundbäck
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Bo Olsson
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
| | - Jeffry Weers
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia (S.A.); Inhaled Delivery Solutions LLC, Durham, North Carolina (P.A.); Emmace Consulting AB Medicon Village, Lund, Sweden (P.B., H.L., B.O.); Insmed Inc., Bridgewater, New Jersey (D.C.); Aerogen Pharma Corporation, San Mateo, California (A.C.); Woolcock Institute of Medical Research, Glebe, New South Wales, Australia (E.D.); Drug Development, Pharmacology and Clinical Pharmacology Consulting, Mainz, Germany (B.D.); Preferred Regulatory Consulting, San Mateo, California (P.E-.D.); Clayton, CA (R.F.); Respidex LLC, Dennis, Massachusetts (I.G.); and cystetic Medicines, Inc., Burlingame, California (J.W.)
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18
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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.
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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
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19
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Wei J, Ho G, Takamatsu Y, Masliah E, Hashimoto M. Therapeutic Potential of α-Synuclein Evolvability for Autosomal Recessive Parkinson's Disease. PARKINSON'S DISEASE 2021; 2021:6318067. [PMID: 34858569 PMCID: PMC8632460 DOI: 10.1155/2021/6318067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 10/20/2021] [Accepted: 11/03/2021] [Indexed: 06/13/2023]
Abstract
The majority of Parkinson's disease (PD) is sporadic in elderly and is characterized by α-synuclein (αS) aggregation and other alterations involving mitochondria, ubiquitin-proteasome, and autophagy. The remaining are familial PD associated with gene mutations of either autosomal dominant or recessive inheritances. However, the former ones are similar to sporadic PD, and the latter ones are accompanied by impaired mitophagy during the reproductive stage. Since no radical therapies are available for PD, the objective of this paper is to discuss a mechanistic role for amyloidogenic evolvability, a putative physiological function of αS, among PD subtypes, and the potential relevance to therapy. Presumably, αS evolvability might benefit familial PD due to autosomal dominant genes and also sporadic PD during reproduction, which may manifest as neurodegenerative diseases through antagonistic pleiotropy mechanism in aging. Indeed, there are some reports describing that αS prevents apoptosis and mitochondrial alteration under the oxidative stress conditions, notwithstanding myriads of papers on the neuropathology of αS. Importantly, β-synuclein (βS), the nonamyloidogenic homologue of αS, might buffer against evolvability of αS protofibrils associated with neurotoxicity. Finally, it is intriguing to predict that increased αS evolvability through suppression of βS expression might protect against autosomal recessive PD. Collectively, further studies are warranted to better understand αS evolvability in PD pathogenesis, leading to rational therapy development.
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Affiliation(s)
- Jianshe Wei
- Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
- Institute for Brain Sciences Research, School of Life Sciences, Henan University, Kaifeng 475004, China
| | - Gilbert Ho
- PCND Neuroscience Research Institute, Poway 92064, CA, USA
| | - Yoshiki Takamatsu
- Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Eliezer Masliah
- Division of Neurosciences, National Institute on Aging, National Institutes of Health, Bethesda, MD, USA
| | - Makoto Hashimoto
- Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
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20
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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.
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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
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21
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Wittung-Stafshede P. Gut power: Modulation of human amyloid formation by amyloidogenic proteins in the gastrointestinal tract. Curr Opin Struct Biol 2021; 72:33-38. [PMID: 34450484 DOI: 10.1016/j.sbi.2021.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/10/2021] [Accepted: 07/19/2021] [Indexed: 01/06/2023]
Abstract
Protein assembly into amyloid fibers underlies many neurodegenerative disorders. In Parkinson's disease, amyloid formation of α-synuclein is linked to brain cell death. The gut-brain axis plays a key role in Parkinson's disease, and initial α-synuclein amyloid formation may occur distant from the brain. Because different amyloidogenic proteins can cross-seed, and α-synuclein is expressed outside the brain, amyloids present in the gut (from food products and secreted by microbiota) may modulate α-synuclein amyloid formation via direct interactions. I here describe existing such data that only began to appear in the literature in the last few years. The striking, but limited, data set-spanning from acceleration to inhibition-calls for additional investigations that may unravel disease mechanisms as well as new treatments.
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Affiliation(s)
- Pernilla Wittung-Stafshede
- Department of Biology and Biological Engineering, Chalmers University of Technology, S-41296, Gothenburg, Sweden.
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22
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Olanow CW, Poewe W, Rascol O, Stocchi F. On-Demand Therapy for OFF Episodes in Parkinson's Disease. Mov Disord 2021; 36:2244-2253. [PMID: 34363424 DOI: 10.1002/mds.28726] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/15/2021] [Accepted: 07/12/2021] [Indexed: 11/10/2022] Open
Abstract
Levodopa is the most effective therapy for Parkinson's disease; however, chronic treatment is associated with the development of OFF episodes, in which there is a return of parkinsonian features following a dose of levodopa and prior to the onset of benefit from the subsequent dose. OFF episodes can be a major source of disability for PD patients and frequently result in depression, apathy and an unwillingness to participate in social activities. Most currently available medical and surgical therapies are designed to reduce total daily OFF time but do not provide a rapid and reliable "on-demand" therapy for individual OFF episodes. Indeed, responses to individual doses of levodopa during an acute OFF episode are unreliable, frequently leading to partial-ON, delayed-ON, or no-ON responses even at different times in the same patient. There are now 3 therapies that are available for the on-demand treatment of OFF episodes; subcutaneous injection of apomorphine, sublingual apomorphine film, and inhaled levodopa. The first has not enjoyed widespread use in the PD community, whereas the latter 2 therapies have only recently been approved. This review will consider the currently available on-demand therapies and their potential advantages and disadvantages. © 2021 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- C Warren Olanow
- Department of Neurology, Mount Sinai School of Medicine, New York, New York, USA.,Clintrex Research Corporation, Sarasota, Florida, USA
| | - Werner Poewe
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Olivier Rascol
- Department of Clinical Pharmacology and Neuroscience, Clinical Investigation Center CIC1436, Parkinson Expert Center, NS-Park/F-CRIN, NeuroToul COEN Center; Toulouse University Hospital, INSERM and University of Toulouse 3, Toulouse, France
| | - Fabrizio Stocchi
- University and Institute for Research and Medical Care, IRCCS San Raffaele Pisana, Rome, Italy
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23
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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.
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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
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24
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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.
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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
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25
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Abstract
Levodopa inhalation powder (Inbrija®) is approved for the intermittent treatment of OFF episodes in patients with Parkinson's disease (PD) treated with levodopa/dopa-decarboxylase inhibitor (LD-DCI) in the EU and specifically with carbidopa/levodopa in the USA. The approved dosage is 84 mg taken as needed up to five times a day. Administered via a breath-actuated inhaler, this formulation enables levodopa to bypass the gastrointestinal (GI) tract and, instead, rapidly enter the bloodstream through the pulmonary system. In the 12-week, double-blind, placebo-controlled, phase III SPAN-PD trial, as-needed levodopa inhalation powder 84 mg improved motor symptoms during OFF periods in PD patients (aged 30-86 years) treated with levodopa and carbidopa or benserazide. The likelihood of achieving an ON state 60 min postdose was significantly higher in the levodopa inhalation powder than the placebo group, with most patients in the levodopa inhalation powder group experiencing improvements in PD symptoms. Findings from longer-term, 52-week phase III studies were consistent with those from the SPAN-PD trial with regards to the treatment of OFF episodes. Levodopa inhalation powder was generally well tolerated and did not noticeably affect pulmonary function in PD patients. Providing a nonintrusive, convenient treatment method, levodopa inhalation powder is a promising option for the intermittent treatment of OFF episodes in patients with PD treated with a LD-DCI.
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Affiliation(s)
- Julia Paik
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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26
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Farbman ES, Waters CH, LeWitt PA, Rudzińska M, Klingler M, Lee A, Qian J, Oh C, Hauser RA. A 12-month, dose-level blinded safety and efficacy study of levodopa inhalation powder (CVT-301, Inbrija) in patients with Parkinson's disease. Parkinsonism Relat Disord 2020; 81:144-150. [DOI: 10.1016/j.parkreldis.2020.10.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 10/07/2020] [Accepted: 10/15/2020] [Indexed: 01/05/2023]
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27
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Abstract
Levodopa is the most effective medication for the treatment of the motor symptoms of Parkinson's disease. However, over time, the clinical response to levodopa becomes complicated by a reduction in the duration and reliability of motor improvement (motor fluctuations) and the emergence of involuntary movements (levodopa-induced dyskinesia). Strategies that have been attempted in an effort to delay the development of these motor complications include levodopa sparing and continuous dopaminergic therapy. Once motor complications occur, a wide array of medical treatments is available to maximize motor function through the day while limiting dyskinesia. Here, we review the clinical features, epidemiology, and risk factors for the development of motor complications, as well as strategies for their prevention and medical management.
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Affiliation(s)
- Stephen D Aradi
- Department of Neurology, Parkinson's Foundation Center of Excellence, University of South Florida, Tampa, FL, USA.
| | - Robert A Hauser
- Department of Neurology, Parkinson's Foundation Center of Excellence, University of South Florida, Tampa, FL, USA
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28
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Levodopa inhalation powder in a patient with persistent asthma. Parkinsonism Relat Disord 2020; 78:44-45. [PMID: 32702523 DOI: 10.1016/j.parkreldis.2020.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/02/2020] [Accepted: 07/12/2020] [Indexed: 11/22/2022]
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29
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Han C, Mao W, An J, Jiao L, Chan P. Early morning off in patients with Parkinson's disease: a Chinese nationwide study and a 7-question screening scale. Transl Neurodegener 2020; 9:29. [PMID: 32624000 PMCID: PMC7336490 DOI: 10.1186/s40035-020-00208-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/14/2020] [Indexed: 12/28/2022] Open
Abstract
Background Early morning off (EMO) is a common feature of Parkinson’s disease (PD). This study aimed to characterize its clinical features and develop a convenient and pragmatic self-assessment instrument in a Chinese nationwide population. Methods This study was conducted on 942 PD patients admitted to 55 clinic centers for movement disorders between June 2018 and May 2019 in China. Stepwise logistic regression analyses were performed to determine potential risk factors and the most predictive symptoms of EMO, as well as whether EMO was an independent risk factor of functional dependency in daily life. Based on this, a 7-question scale was derived for EMO screening. Diagnostic accuracy of this scale was assessed from the area under the receiver operative characteristic curve (AUROC) and its 95% confidence intervals (CIs). We further calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the optimal cutoff point. Results EMO occurred in 49.2% of PD patients across all disease stages. We identified 7 symptoms most predictive of EMO, including bradykinesia or rigidity, excessive sweating or salivation, difficulty in turning on or getting out of bed, muscle cramp, fatigue or sleepiness, frozen state or freezing gait, and tremor. The resulting 7-item scale was confirmed to be of good discrimination with a relatively large AUROC of 0.83, a relatively high sensitivity of 75.7%, specificity of 77.5%, PPV of 76.5%, and NPV of 76.7%. Nonideal nighttime sleep, long PD duration, advanced H&Y stages, posture instability gait difficulty-dominant or mixed subtypes, and high levodopa dose were independently associated with increased risk of EMO. EMO patients were at 87% higher (OR = 1.87, 95%CI: 1.07–3.32) risk of experiencing functional dependency in daily living compared with their counterparts. Conclusions We demonstrated that EMO is a common feature for PD patients across all disease stages and put forward an EMO-specific screening card of sufficient accuracy and brevity. Meanwhile we have thrown some light upon potential determinants and negative health effects of EMO. Our findings may exert great impact on improving the awareness, recognition and management of EMO in PD patients.
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Affiliation(s)
- Chao Han
- National Clinical Research Center for Geriatric Disorders, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Wei Mao
- Department of Neurobiology, Neurology and Geriatrics, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China.,Beijing Institute of Geriatrics, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China.,Clinical Center for Parkinson's Disease, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China.,Key Laboratories for Neurodegenerative Diseases of the Ministry of Education, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China.,Beijing Key Laboratory for Parkinson's Disease, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China.,Parkinson Disease Center of Beijing Institute for Brain Disorders, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China.,Advanced Innovative Center for Human Brain Protection, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China
| | - Jing An
- National Clinical Research Center for Geriatric Disorders, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Lifei Jiao
- Medical department, Lundbeck (Beijing) Pharmaceutical Co. ltd, Beijing, China
| | - Piu Chan
- National Clinical Research Center for Geriatric Disorders, Xuanwu Hospital of Capital Medical University, Beijing, China. .,Department of Neurobiology, Neurology and Geriatrics, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China. .,Beijing Institute of Geriatrics, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China. .,Clinical Center for Parkinson's Disease, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China. .,Key Laboratories for Neurodegenerative Diseases of the Ministry of Education, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China. .,Beijing Key Laboratory for Parkinson's Disease, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China. .,Parkinson Disease Center of Beijing Institute for Brain Disorders, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China. .,Advanced Innovative Center for Human Brain Protection, Xuanwu Hospital of Capital Medical University, 45 Changchun Road, Beijing, 100053, China.
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30
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Safirstein BE, Ellenbogen A, Zhao P, Henney HR, Kegler-Ebo DM, Oh C. Pharmacokinetics of Inhaled Levodopa Administered With Oral Carbidopa in the Fed State in Patients With Parkinson's Disease. Clin Ther 2020; 42:1034-1046. [DOI: 10.1016/j.clinthera.2020.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/26/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
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31
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Simões RM, Castro Caldas A, Ferreira JJ. Inhaled levodopa for intermittent treatment of OFF episodes in patients with Parkinson's disease. Expert Rev Clin Pharmacol 2020; 13:85-101. [PMID: 32011195 DOI: 10.1080/17512433.2020.1724535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Many patients with advanced Parkinson's disease (PD) have inadequate control of motor symptoms despite optimized treatment. Predictable and unpredictable OFF periods severely interfere with the quality of life. A drug that easily and rapidly reverts the OFF state is still needed. Subcutaneous apomorphine, the only approved drug for this indication, although efficacious, is not widely used probably due to its potential side effects and complicated administration.Levodopa is the most efficacious drug for the treatment of PD motor symptoms. However, issues related to the oral route and intestinal absorption in later disease stages render this route lengthy and inefficacious.Areas covered: Literature on the development of an inhaled formulation of levodopa has been reviewed. Significant advances in the field of pulmonary delivery systems and in dry powders have enabled the development of a new formulation of levodopa that can be inhaled and adequate blood levels rapidly achieved, bypassing intestinal absorption. Several clinical trials have reported efficacy, safety, and tolerability data. Some pulmonary-related adverse events have been reported but are mostly mild.Expert opinion: This new way of administering levodopa is likely to be very welcome and may fill a gap for OFF rescue treatments, at least for some patients.
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Affiliation(s)
- Rita Moiron Simões
- Neurology Department, Hospital Beatriz Ângelo, Loures, Portugal.,CNS-Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Ana Castro Caldas
- CNS-Campus Neurológico Sénior, Torres Vedras, Portugal.,Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Joaquim J Ferreira
- CNS-Campus Neurológico Sénior, Torres Vedras, Portugal.,Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Laboratory of Clinical Pharmacology and Therapeutics, Universidade de Lisboa, Lisbon, Portugal
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32
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Inhaled levodopa in Parkinson's disease patients with OFF periods: A randomized 12-month pulmonary safety study. Parkinsonism Relat Disord 2019; 71:4-10. [PMID: 31927343 DOI: 10.1016/j.parkreldis.2019.12.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/20/2019] [Accepted: 12/20/2019] [Indexed: 11/23/2022]
Abstract
INTRODUCTION CVT-301 is an orally inhaled levodopa therapy approved for the intermittent treatment of OFF episodes in Parkinson's disease patients who are taking a standard oral levodopa regimen. This open-label, randomized, controlled study over 12 months characterizes the safety, including pulmonary safety, of CVT-301 84 mg (nominal respirable levodopa fine-particle dose, 50 mg). METHODS Patients experiencing motor fluctuations were randomized 2:1 to CVT-301 or an observational cohort (OC) receiving oral standard of care. Pulmonary safety was assessed using spirometry and carbon monoxide diffusion capacity (DLCO). Exploratory efficacy endpoints, assessed only for CVT-301, included change in Unified Parkinson's Disease Rating Scale Part III (UPDRS-III), patients achieving ON within 60 min and remaining ON at 60 min, Patient Global Impression of Change (PGIC) scale, and total daily OFF time. RESULTS Of 408 patients randomized, 310 completed the study (204 in CVT-301 and 106 in OC). Mean 12-month changes from baseline for CVT-301 were -0.105 L (FEV1) and -0.378 mL/min/mm Hg (DLCO), and for OC were -0.117 L and -0.722 mL/min/mm Hg, respectively. Between-group comparisons were not statistically significant. For FEV1/FVC the 12-month change was -0.3 and -1.6, respectively, which was a significant between-group difference. However, between-group differences were not significant at 3 and 9 months and all changes from baseline were small (<2.0%). UPDRS-III scores improved from predose to 60 min postdose at all assessments; 80%-85% of patients switched ON within 60 min and remained ON; and >75% reported improvement in PGIC. OFF time decreased by 1.32-1.42 h/day. CONCLUSION CVT-301 84 mg induced no clinically significant differences in pulmonary function compared with the OC. Improvements in motor scores, OFF time, and patient-reported outcomes support clinical efficacy for up to 12 months.
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Zhang Y, Li Z, Tang H, Ren W, Gao X, Sun Y, Zhao QX, Wang F, Liu J. Development and optimization of levodopa and benzylhydrazine orally disintegrating tablets by direct compression and response surface methodology. Drug Dev Ind Pharm 2019; 46:42-49. [PMID: 31794271 DOI: 10.1080/03639045.2019.1698597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The number of Parkinson's disease (PD) patients with the advanced phase and motor fluctuations is increasing. The objective of this study is developing levodopa/benzylhydrazine orally disintegrating tablets (L/B ODTs), which would provide greater convenience and ease of use than conventional tablets for these patients. In the present study, the L/B ODTs were developed successfully with an optimized formulation using response surface methodology (RSM). The direct compression technology was employed for the preparation of L/B ODTs. Considerably shorter disintegration time and faster dissolution profile were obtained under the optimum formulation with microcrystalline cellulose 25.7%, cross-polyvinylpyrrolidone 6.22% and Sodium carboxymethyl starch 5.36%. The content uniformity (%) of levodopa and benzylhydrazine was 50 ± 1.4% and 14.25 ± 0.6%, respectively. Thickness, friability, hardness and wetting time were 2.8 ± 0.05 mm, 0.46 ± 0.21%, 5.42 ± 1.1 kp and 31.2 ± 2.1 s, respectively, and all of data well comply with the General Principles of the Chinese Pharmacopeia. Mannitol of 22% in formulation could bring a pleasant taste: sweet, cool and refreshing. Almost all the volunteers felt that the ODTs had good taste, no roughness, and no gritty feeling, indicating that the ODTs prepared had good palatability, so patients will have good compliance when taking medicine.
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Affiliation(s)
- Yuanyuan Zhang
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao, China.,Department of Pharmaceutical Engineering, College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao, China
| | - Zewen Li
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao, China
| | - Hui Tang
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao, China
| | - Wenjie Ren
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao, China
| | - Xin Gao
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao, China
| | - Yangjian Sun
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao, China
| | - Qiu Xiang Zhao
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao, China
| | - Fanye Wang
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao, China
| | - Junhong Liu
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao, China
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Carrarini C, Russo M, Dono F, Di Pietro M, Rispoli MG, Di Stefano V, Ferri L, Barbone F, Vitale M, Thomas A, Sensi SL, Onofrj M, Bonanni L. A Stage-Based Approach to Therapy in Parkinson's Disease. Biomolecules 2019; 9:biom9080388. [PMID: 31434341 PMCID: PMC6723065 DOI: 10.3390/biom9080388] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/31/2019] [Accepted: 08/14/2019] [Indexed: 12/11/2022] Open
Abstract
Parkinson’s disease (PD) is a neurodegenerative disorder that features progressive, disabling motor symptoms, such as bradykinesia, rigidity, and resting tremor. Nevertheless, some non-motor symptoms, including depression, REM sleep behavior disorder, and olfactive impairment, are even earlier features of PD. At later stages, apathy, impulse control disorder, neuropsychiatric disturbances, and cognitive impairment can present, and they often become a heavy burden for both patients and caregivers. Indeed, PD increasingly compromises activities of daily life, even though a high variability in clinical presentation can be observed among people affected. Nowadays, symptomatic drugs and non-pharmaceutical treatments represent the best therapeutic options to improve quality of life in PD patients. The aim of the present review is to provide a practical, stage-based guide to pharmacological management of both motor and non-motor symptoms of PD. Furthermore, warning about drug side effects, contraindications, as well as dosage and methods of administration, are highlighted here, to help the physician in yielding the best therapeutic strategies for each symptom and condition in patients with PD.
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Affiliation(s)
- Claudia Carrarini
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Mirella Russo
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Martina Di Pietro
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Marianna G Rispoli
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Vincenzo Di Stefano
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Filomena Barbone
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Michela Vitale
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Astrid Thomas
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Stefano Luca Sensi
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy
| | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, 66100 Chieti, Italy.
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