A noninterventional study evaluating the effectiveness of rotigotine and levodopa combination therapy in younger versus older patients with Parkinson's disease

Pharmacological and non-pharmacological management of sleep disturbances in Parkinson's disease: if when and how

INTRODUCTION

Sleep dysfunction occurs in various forms and is a bothersome and intrusive non-motor symptom of Parkinson's disease (PD). Frequently undiagnosed, their poor management can have a great impact on the quality of life of PD patients and their caregivers.

AREAS COVERED

This article covers the safety and efficacy of pharmacological strategies for the management of the most frequent sleep disturbances in Parkinson's disease. Non-pharmacological aspects are also discussed, but these are not the main focus. Literature searches using electronic databases (Medline, Cochrane Library) and systematic checking of references from review articles/other reports were performed.

EXPERT OPINION

Melatonin and clonazepam are the most commonly used therapies for the management of REM sleep behavior disorder (RBD). The most used pharmacological wake-promoting agents in the treatment of excessive daytime sleepiness (EDS) are modafinil and caffeine. Poor nocturnal sleep quality is usually linked to EDS, thus proper sleep hygiene is recommended. As nocturnal motor symptoms are commonly associated with sleep fragmentation and early morning off, optimization of dopaminergic treatment during nighttime is highly recommended for the proper management of insomnia. Further interventions include eszopiclone and melatonin for the management of insomnia. Therapeutic options for restless legs syndrome (RLS) include calcium channel alpha-2-delta ligands and low-dose dopamine agonists (DA). Further confirmatory evidence is needed before the general recommendation of these treatments.

Carboxymethyl cellulose-based rotigotine nanocrystals-loaded hydrogel for increased transdermal delivery with alleviated skin irritation

Transdermal rotigotine (RTG) therapy is prescribed to manage Parkinson's disease (Neupro® patch). However, its use is suffered from application site reactions. Herein, drug nanocrystalline suspension (NS)-loaded hydrogel (NS-HG) employing polysaccharides simultaneously as suspending agent and hydrogel matrix was constructed for transdermal delivery, with alleviated skin irritation. RTG-loaded NS-HG was prepared using a bead-milling technique, employing sodium carboxylmethyl cellulose (Na.CMC) as nano-suspending agent (molecular weight 90,000 g/mol) and hydrogel matrix (700,000 g/mol), respectively. NS-HG was embodied as follows: drug loading: ≤100 mg/mL; shape: rectangular crystalline; crystal size: <286.7 nm; zeta potential: -61 mV; viscosity: <2.16 Pa·s; and dissolution rate: >90 % within 15 min. Nuclear magnetic resonance analysis revealed that the anionic polymers bind to RTG nanocrystals via charge interaction, affording uniform dispersion in the matrix. Rodent transdermal absorption of RTG from NS-HG was comparable to that from microemulsions, and proportional to drug loading. Moreover, NS-HG was skin-friendly; erythema and epidermal swelling were absent after repeated application. Further, NS-HG was chemically stable; >95 % of the drug was preserved up to 4 weeks under long term (25 °C/RH60%), accelerated (40 °C/RH75%), and stress (50 °C) storage conditions. Therefore, this novel cellulose derivative-based nanoformulation presents a promising approach for effective transdermal RTG delivery with improved tolerability.

A Systematic Review of the Usage of Rotigotine During Early and Advanced Stage Parkinson's

Parkinson's disease (PD) is a prevalent neurodegenerative disorder that occurs in old age due to a decrease in dopamine, which causes nerve cell destruction. This disease is difficult to diagnose since its symptoms are similar to those of the aging process. Those with PD have impaired motor control and function, dyskinesia, and tremors. To treat PD, drugs that enhance the amount of dopamine given to the brain are administered to alleviate symptoms. This inquiry examines the prescription of rotigotine to achieve this objective. The primary objective of this review is to examine the usage of rotigotine in both the late and early stages of PD. The statistical model utilized in the review found that there was not a significant difference in the dosage of rotigotine prescribed to late and early-stage PD patients, however, there were some confounding variables that may have skewed this result; therefore, further research is necessary to validate or nullify this hypothesis.

Advances in the Pharmacological and Non-pharmacological Management of Non-motor Symptoms in Parkinson's Disease: An Update Since 2017

BACKGROUND

Non-motor symptoms (NMS) are an important and ubiquitous determinant of quality of life in Parkinson's disease (PD). However, robust evidence for their treatment is still a major unmet need.

OBJECTIVE

This study aimed to provide an updated review on advances in pharmacological, nonpharmacological, and exercise-based interventions for NMS in PD, covering the period since the publication of the MDS Task Force Recommendations.

METHODS

We performed a literature search to identify pharmacological, non-pharmacological, and exercise-based interventions for NMS in PD. As there are recent reviews on the subject, we have only included studies from the 1st of January 2017 to the 1st of December 2021 and limited our search to randomised and non-randomised (including open-label) clinical trials.

RESULTS

We discuss new strategies to manage NMS based on data that have become available since 2017, for instance, on the treatment of orthostatic hypotension with droxidopa, several dopaminergic treatment options for insomnia, and a range of non-pharmacological and exercise-based interventions for cognitive and neuropsychiatric symptoms, pain, and insomnia and excessive sleepiness.

CONCLUSION

Recent evidence suggests that targeted non-pharmacological treatments, as well as some other NMS management options, may have a significant beneficial effect on the quality of life and need to be considered in the pathways of treatment of PD.

The Effect of Rotigotine on Cognitive Function, Daytime Sleepiness, and Sleep Problems in Parkinson Disease: An Open-Label Pilot Study

BACKGROUND

We hypothesized that rotigotine may have a positive effect on cognitive function in patients with Parkinson disease (PD) by improving daytime motor function and sleep status.

METHODS

Fifteen PD patients with sleep disturbances, defined as a PD Sleep Scale (PDSS)-2 score of 15 or greater, were included in this single-center, 3-month open-label study. Participants received 2 to 4 mg/24 h (patch content: 4.5-9 mg) rotigotine for a 3-month period. At baseline and 3 months, the patients were evaluated on the Movement Disorder Society Revision of the Unified PD Rating Scale (MDS-UPDRS) parts III and IV and cognitive assessments, such as the Mini-Mental State Examination, frontal assessment battery, and Montreal Cognitive Assessment (MoCA). The Epworth Sleepiness Scale (ESS) and PDSS-2 were administered at baseline and at 1, 2, and 3 months.

RESULTS

At 3 months, the MDS-UPDRS part III (-11.1, P < 0.0001) and MDS-UPDRS part IV (-1.1, P = 0.0013) scores significantly decreased, and off time significantly decreased (-34.6 minutes, P = 0.0085) from baseline. The PDSS-2 scores significantly decreased from baseline at 1 month (-4.2, P < 0.01), 2 months (-7.7, P < 0.0001), and 3 months (-7.3, P < 0.0001). The ESS also decreased at 1 month (-2.5, P < 0.05) and 3 months from baseline (-4.5, P < 0.01). The MoCA scores (1.6, P = 0.0029) significantly improved, but the Mini-Mental State Examination or frontal assessment battery scores did not significantly change. The mean changes from baseline to 3 months in the MoCA were negatively correlated with mean changes in the ESS scores.

CONCLUSIONS

We suggest that rotigotine could improve cognitive function by improving motor symptoms, sleep disturbance, and daytime sleepiness in patients with PD.

Rotigotine Transdermal Patch for Motor and Non-motor Parkinson's Disease: A Review of 12 Years' Clinical Experience

Motor and non-motor symptoms (NMS) have a substantial effect on the health-related quality of life (QoL) of patients with Parkinson's disease (PD). Transdermal therapy has emerged as a time-tested practical treatment option, and the rotigotine patch has been used worldwide as an alternative to conventional oral treatment for PD. The efficacy of rotigotine on motor aspects of PD, as well as its safety and tolerability profile, are well-established, whereas its effects on a wide range of NMS have been described and studied but are not widely appreciated. In this review, we present our overall experience with rotigotine and its tolerability and make recommendations for its use in PD and restless legs syndrome, with a specific focus on NMS, underpinned by level 1-4 evidence. We believe that the effective use of the rotigotine transdermal patch can address motor symptoms and a wide range of NMS, improving health-related QoL for patients with PD. More specifically, the positive effects of rotigotine on non-motor fluctuations are also relevant. We also discuss the additional advantages of the transdermal application of rotigotine when oral therapy cannot be used, for instance in acute medical emergencies or nil-by-mouth or pre/post-surgical scenarios. We highlight evidence to support the use of rotigotine in selected cases (in addition to general use for motor benefit) in the context of personalised medicine.

Rotigotine Transdermal Patch: A Review in Parkinson's Disease

Rotigotine (Neupro^®), a non-ergolinic dopamine agonist (DA), is administered once daily via a transdermal patch (TP) that delivers the drug over a 24-h period. In the EU, the rotigotine TP is approved as monotherapy for the treatment of early Parkinson's disease (PD) and as combination therapy with levodopa throughout the course of the disease. It is also approved for the treatment of PD in numerous other countries, including Australia, the USA, China and Japan. Rotigotine TP effectively improved motor and overall functioning in clinical trials in Caucasian and Asian patients with early PD (as monotherapy) or advanced PD (in combination with levodopa); treatment benefits appeared to be maintained in open-label extensions that followed patients for up to 6 years. Rotigotine TP was not consistently non-inferior to ropinirole and pramipexole in studies that included these oral non-ergolinic DAs as active comparators. Rotigotine TP variously improved some non-motor symptoms of PD, in particular sleep disturbances and health-related quality of life (HRQOL), based on findings from individual studies and/or a meta-analysis. Rotigotine TP was generally well tolerated, with an adverse event profile characterized by adverse events typical of dopaminergic stimulation and transdermal patch application. Available for more than a decade, rotigotine TP is a well-established, once-daily DA formulation for use in the short- and longer-term treatment of PD. It offers a convenient alternative when non-oral administration of medication is preferred and may be particularly useful in patients with gastrointestinal disturbances that reduce the suitability of oral medication.