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Richmond AM, Lyons KE, Pahwa R. Safety review of current pharmacotherapies for levodopa-treated patients with Parkinson's disease. Expert Opin Drug Saf 2023; 22:563-579. [PMID: 37401865 DOI: 10.1080/14740338.2023.2227096] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/15/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Levodopa remains the gold standard for treatment of Parkinson's disease (PD). Patients develop complications with disease progression, necessitating adjunctive therapy to control fluctuations in motor and non-motor symptoms and dyskinesia. Knowledge of medication safety and tolerability is critical to ascertain the benefit-risk ratio and select an adjunctive therapy that provides the highest chance for medication adherence. Posing a challenge are the sheer abundance of options, stemming from the development of several new drugs in recent years, as well as differences in commercial drug availability worldwide. AREAS COVERED This review evaluates the efficacy, safety, and tolerability of current US FDA-approved pharmacotherapies for levodopa-treated PD patients, including dopamine agonists, monoamine oxidase type-B inhibitors, catechol-O-methyltransferase inhibitors, the N-methyl-D-aspartate receptor antagonist amantadine, and the adenosine receptor antagonist istradefylline. Data were taken from pivotal phase III randomized controlled and post-surveillance studies, when available, that directly led to FDA-approval. EXPERT OPINION No strong evidence exists to support use of a specific adjunctive treatment for improving Off time. Only one medication has demonstrated improvement in dyskinesia in levodopa-treated PD patients; however, every patient cannot tolerate it and therefore adjunctive therapy should be tailored to an individual's symptoms and risk for specific adverse effects.
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Affiliation(s)
- Angela M Richmond
- Parkinson's and Movement Disorders Division, Department of Neurology, The University of Kansas Medical Center, Kansas, KS, United States of America
| | - Kelly E Lyons
- Research and Education, Parkinson's and Movement Disorders Division, Department of Neurology, The University of Kansas Medical Center, Kansas, KS, United States of America
| | - Rajesh Pahwa
- Laverne & Joyce Rider Professor of Neurology, Chief, Parkinson's and Movement Disorders Division Director, Parkinson's Foundation Center of Excellence, The University of Kansas Medical Center, Kansas, KS, United States of America
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2
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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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3
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Martinez-Nunez AE, LeWitt PA. Drugs to the Rescue: Comparison of On-Demand Therapies for OFF Symptoms in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2023:JPD230055. [PMID: 37182902 DOI: 10.3233/jpd-230055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Patients with Parkinson's disease often suffer from OFF symptoms disrupting their daily routines and adding to disabilities. Despite polypharmacy and adjustments to medication schedules, they often do not experience consistent relief from their motor symptoms. As the disease progresses, impaired gastric emptying may evolve, making it even more challenging for dopaminergic drugs to provide consistent results. This review focuses on a group of drugs that have the pharmacokinetic advantage of a much earlier onset of action by virtue of their non-oral routes of absorption. We compare the current marketed options: subcutaneous apomorphine, sublingual apomorphine, and inhaled levodopa. Subcutaneous apomorphine is the speediest to take effect, whereas sublingual apomorphine offers the longest clinical effect. Inhaled levodopa has the most favorable side effect profile among the three options. An inhaled form of apomorphine is currently under development, having passed safety and efficacy studies. Each of these drugs has unique characteristics for the user, including different side effect profiles and onset of action. The best choice for a patient will depend on individual needs and circumstances. In this review, we explore those nuances to allow clinicians to select the best option for their patients.
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Affiliation(s)
| | - Peter A LeWitt
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
- Department of Neurology and Sastry Foundation Endowed Chair In Neurology, Wayne State University School of Medicine, Detroit, MI, USA
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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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Masood N, Jimenez-Shahed J. Effective Management of "OFF" Episodes in Parkinson's Disease: Emerging Treatment Strategies and Unmet Clinical Needs. Neuropsychiatr Dis Treat 2023; 19:247-266. [PMID: 36721795 PMCID: PMC9884436 DOI: 10.2147/ndt.s273121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/05/2023] [Indexed: 01/26/2023] Open
Abstract
Motor complications related to the chronic administration of levodopa and failure to prevent the neurodegenerative disease process counterbalance the pivotal discovery of levodopa as the cornerstone of PD treatment. Excellent motor control is offered early during the course of treatment, but this diminishes as pathological changes in the striatum lead to synaptic dopamine levels becoming completely dependent on exogenous dopamine. This non-physiologic stimulation of dopamine receptors eventually manifests as OFF episodes. As no disease modifying therapy exists for PD that can disrupt these pathological changes, most research and treatment focuses on optimization of dopaminergic stimulation of striatal receptors so that they mimic tonic, physiologic stimulation as closely as possible. Strategies focusing on these challenges have included non-pharmacologic approaches, optimizing levodopa pharmacokinetics, using adjunctive treatments including those with non-dopaminergic mechanisms, and implementing rescue therapies. Device aided therapies, including surgery, are also available. In this review, we will focus on effective management of motor symptoms related to OFF periods, including emerging strategies. Unmet clinical needs will be discussed, including non-motor symptoms, targeted molecular therapies and disease modifying therapy.
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Affiliation(s)
- Nbaa Masood
- Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai West, New York, NY, USA
| | - Joohi Jimenez-Shahed
- Department of Neurology, Icahn School of Medicine at Mount Sinai, Mount Sinai West, New York, NY, USA
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6
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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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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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8
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Son YJ, Miller DP, Weers JG. Optimizing Spray-Dried Porous Particles for High Dose Delivery with a Portable Dry Powder Inhaler. Pharmaceutics 2021; 13:pharmaceutics13091528. [PMID: 34575603 PMCID: PMC8470347 DOI: 10.3390/pharmaceutics13091528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 11/16/2022] Open
Abstract
This manuscript critically reviews the design and delivery of spray-dried particles for the achievement of high total lung doses (TLD) with a portable dry powder inhaler. We introduce a new metric termed the product density, which is simply the TLD of a drug divided by the volume of the receptacle it is contained within. The product density is given by the product of three terms: the packing density (the mass of powder divided by the volume of the receptacle), the drug loading (the mass of drug divided by the mass of powder), and the aerosol performance (the TLD divided by the mass of drug). This manuscript discusses strategies for maximizing each of these terms. Spray drying at low drying rates with small amounts of a shell-forming excipient (low Peclet number) leads to the formation of higher density particles with high packing densities. This enables ultrahigh TLD (>100 mg of drug) to be achieved from a single receptacle. The emptying of powder from capsules is directly proportional to the mass of powder in the receptacle, requiring an inhaled volume of about 1 L for fill masses between 40 and 50 mg and up to 3.2 L for a fill mass of 150 mg.
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Affiliation(s)
- Yoen-Ju Son
- Genentech, South San Francisco, CA 94080, USA;
| | | | - Jeffry G. Weers
- Cystetic Medicines, Inc., Burlingame, CA 94010, USA;
- Correspondence: ; Tel.: +1-650-339-3832
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9
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Baptista MAS, Merchant K, Barrett T, Bhargava S, Bryce DK, Ellis JM, Estrada AA, Fell MJ, Fiske BK, Fuji RN, Galatsis P, Henry AG, Hill S, Hirst W, Houle C, Kennedy ME, Liu X, Maddess ML, Markgraf C, Mei H, Meier WA, Needle E, Ploch S, Royer C, Rudolph K, Sharma AK, Stepan A, Steyn S, Trost C, Yin Z, Yu H, Wang X, Sherer TB. LRRK2 inhibitors induce reversible changes in nonhuman primate lungs without measurable pulmonary deficits. Sci Transl Med 2021; 12:12/540/eaav0820. [PMID: 32321864 DOI: 10.1126/scitranslmed.aav0820] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 07/22/2019] [Indexed: 12/27/2022]
Abstract
The kinase-activating mutation G2019S in leucine-rich repeat kinase 2 (LRRK2) is one of the most common genetic causes of Parkinson's disease (PD) and has spurred development of LRRK2 inhibitors. Preclinical studies have raised concerns about the safety of LRRK2 inhibitors due to histopathological changes in the lungs of nonhuman primates treated with two of these compounds. Here, we investigated whether these lung effects represented on-target pharmacology and whether they were reversible after drug withdrawal in macaques. We also examined whether treatment was associated with pulmonary function deficits. We conducted a 2-week repeat-dose toxicology study in macaques comparing three different LRRK2 inhibitors: GNE-7915 (30 mg/kg, twice daily as a positive control), MLi-2 (15 and 50 mg/kg, once daily), and PFE-360 (3 and 6 mg/kg, once daily). Subsets of animals dosed with GNE-7915 or MLi-2 were evaluated 2 weeks after drug withdrawal for lung function. All compounds induced mild cytoplasmic vacuolation of type II lung pneumocytes without signs of lung degeneration, implicating on-target pharmacology. At low doses of PFE-360 or MLi-2, there was ~50 or 100% LRRK2 inhibition in brain tissue, respectively, but histopathological lung changes were either absent or minimal. The lung effect was reversible after dosing ceased. Lung function tests demonstrated that the histological changes in lung tissue induced by MLi-2 and GNE-7915 did not result in pulmonary deficits. Our results suggest that the observed lung effects in nonhuman primates in response to LRRK2 inhibitors should not preclude clinical testing of these compounds for PD.
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Affiliation(s)
- Marco A S Baptista
- The Michael J. Fox Foundation for Parkinson's Research, Grand Central Station, P.O. Box 4777, New York, NY 10001, USA.
| | - Kalpana Merchant
- Northwestern University School of Medicine, Chicago, IL 60611, USA
| | - Ted Barrett
- Lovelace Respiratory Research Institute, Albuquerque, NM 87108, USA
| | - Sakshi Bhargava
- Pfizer Inc., Neuroscience Research Unit, Cambridge, MA 02139, USA
| | - Dianne K Bryce
- Merck Research Laboratories, Early Discovery Neuroscience, Boston, MA 02115, USA
| | - J Michael Ellis
- Merck Research Laboratories, Early Discovery Neuroscience, Boston, MA 02115, USA
| | | | - Matthew J Fell
- Merck Research Laboratories, Early Discovery Neuroscience, Boston, MA 02115, USA
| | - Brian K Fiske
- The Michael J. Fox Foundation for Parkinson's Research, Grand Central Station, P.O. Box 4777, New York, NY 10001, USA
| | - Reina N Fuji
- Genentech, Inc., South San Francisco, CA 94080, USA
| | - Paul Galatsis
- Pfizer Inc., Neuroscience Research Unit, Cambridge, MA 02139, USA
| | | | - Sue Hill
- Merck Research Laboratories, Early Discovery Neuroscience, Boston, MA 02115, USA
| | - Warren Hirst
- Pfizer Inc., Neuroscience Research Unit, Cambridge, MA 02139, USA
| | | | - Matthew E Kennedy
- Merck Research Laboratories, Early Discovery Neuroscience, Boston, MA 02115, USA
| | - Xingrong Liu
- Genentech, Inc., South San Francisco, CA 94080, USA
| | - Matthew L Maddess
- Merck Research Laboratories, Early Discovery Neuroscience, Boston, MA 02115, USA
| | - Carrie Markgraf
- Merck Research Laboratories, Early Discovery Neuroscience, Boston, MA 02115, USA
| | - Hong Mei
- Merck Research Laboratories, Early Discovery Neuroscience, Boston, MA 02115, USA
| | | | - Elie Needle
- Pfizer Inc., Neuroscience Research Unit, Cambridge, MA 02139, USA
| | | | | | - Karin Rudolph
- Lovelace Respiratory Research Institute, Albuquerque, NM 87108, USA
| | | | - Antonia Stepan
- Pfizer Inc., Neuroscience Research Unit, Cambridge, MA 02139, USA
| | - Stefan Steyn
- Pfizer Inc., Neuroscience Research Unit, Cambridge, MA 02139, USA
| | - Craig Trost
- Covance Laboratories, Inc., Madison, WI 53704, USA
| | - Zhizhang Yin
- Merck Research Laboratories, Early Discovery Neuroscience, Boston, MA 02115, USA
| | - Hongshi Yu
- Merck Research Laboratories, Early Discovery Neuroscience, Boston, MA 02115, USA
| | - Xiang Wang
- Denali Therapeutics, South San Francisco, CA 94080, USA
| | - Todd B Sherer
- The Michael J. Fox Foundation for Parkinson's Research, Grand Central Station, P.O. Box 4777, New York, NY 10001, USA
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10
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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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11
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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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12
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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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13
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Pfeiffer RF, Isaacson SH, Pahwa R. Clinical implications of gastric complications on levodopa treatment in Parkinson's disease. Parkinsonism Relat Disord 2020; 76:63-71. [PMID: 32461054 DOI: 10.1016/j.parkreldis.2020.05.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/09/2020] [Accepted: 05/01/2020] [Indexed: 12/16/2022]
Abstract
Disorders of the gastrointestinal (GI) tract are common and distressing nonmotor symptoms of Parkinson's disease (PD) that can adversely affect levodopa absorption and lead to OFF periods, also known as motor fluctuations. Gastroparesis, which is primarily defined as delayed gastric emptying (DGE), and Helicobacter pylori infection, which is present with increased frequency in PD, are among the most common and important GI disorders reported in PD that may impair oral levodopa absorption and increase OFF time. Symptoms of gastroparesis include nausea, vomiting, postprandial bloating, fullness, early satiety, abdominal pain, and weight loss. DGE has been reported in a substantial fraction of individuals with PD. Symptoms of H. pylori infection include gastritis and peptic ulcers. Studies have found that DGE and H. pylori infection are correlated with delayed peak levodopa plasma levels and increased incidence of motor fluctuations. Therapeutic strategies devised to minimize the potential that gastric complications will impair oral levodopa absorption and efficacy in PD patients include treatments that circumvent the GI tract, such as apomorphine injection, levodopa intestinal gel delivery, levodopa inhalation powder, and deep brain stimulation. Other strategies aim at improving gastric emptying in PD patients, primarily including prokinetic agents.
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Affiliation(s)
- Ronald F Pfeiffer
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA.
| | - Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, USA
| | - Rajesh Pahwa
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
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14
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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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15
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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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16
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Moon C, Sahakijpijarn S, Koleng JJ, Williams RO. Processing design space is critical for voriconazole nanoaggregates for dry powder inhalation produced by thin film freezing. J Drug Deliv Sci Technol 2019. [DOI: 10.1016/j.jddst.2019.101295] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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17
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Nagao KJ, Patel NJ. From medications to surgery: advances in the treatment of motor complications in Parkinson's disease. Drugs Context 2019; 8:212592. [PMID: 31516532 PMCID: PMC6727789 DOI: 10.7573/dic.212592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/19/2019] [Accepted: 06/25/2019] [Indexed: 11/21/2022] Open
Abstract
Motor complications are responsible for the large burden of disability and poor quality of life in Parkinson’s disease (PD). The pulsatile nature of stimulation with oral dopaminergic therapies due to relatively short pharmacokinetic profiles and dysfunctional gastrointestinal absorption have been attributed to the development of PD motor complications. In this review, we will provide an overview of the pharmacologic and surgical therapies currently available and under investigation for the treatment of motor fluctuations and dyskinesia.
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Affiliation(s)
- Kanae Jennifer Nagao
- Department of Neurology, Henry Ford Health System, West Bloomfield, Michigan, USA
| | - Neepa J Patel
- Department of Neurology, Henry Ford Health System, West Bloomfield, Michigan, USA
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18
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Zhang W, Zhang L, Zhou N, Huang E, Li Q, Wang T, Ma C, Li B, Li C, Du Y, Zhang J, Lei X, Ross A, Sun H, Zhu X. Dysregulation of Respiratory Center Drive (P0.1) and Muscle Strength in Patients With Early Stage Idiopathic Parkinson's Disease. Front Neurol 2019; 10:724. [PMID: 31333573 PMCID: PMC6618698 DOI: 10.3389/fneur.2019.00724] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 06/18/2019] [Indexed: 12/20/2022] Open
Abstract
Objective: The goal of this study is to evaluate pulmonary function and respiratory center drive in patients with early-stage idiopathic Parkinson's disease (IPD) to facilitate early diagnosis of Parkinson's Disease (PD). Methods: 43 IPD patients (Hoehn and Yahr scale of 1) and 41 matched healthy individuals (e.g., age, sex, height, weight, BMI) were enrolled in this study. Motor status was evaluated using the Movement Disorders Society-Unified PD Rating Scale (MDS-UPDRS). Pulmonary function and respiratory center drive were measured using pulmonary function tests (PFT). All IPD patients were also subjected to a series of neuropsychological tests, including Non-Motor Symptoms Questionnaire (NMSQ), REM Sleep Behavior Disorder Screening Questionnaire (RBDSQ), Beck Depression Inventory (BDI) and Mini Mental State Examination (MMSE). Results: IPD patients and healthy individuals have similar forced vital capacity (FVC), forced expiratory volume in 1s (FEV1), forced expiratory volume in 1s/forced vital capacity (FEV1/FVC), peak expiratory flow (PEF), and carbon monoxide diffusion capacity (DLCOcSB). Reduced respiratory muscle strength, maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax) was seen in IPD patients (p = 0.000 and p = 0.002, respectively). Importantly, the airway occlusion pressure after 0.1 s (P0.1) and respiratory center output were notably higher in IPD patients (p = 0.000) with a remarkable separation of measured values compared to healthy controls. Conclusion: Our findings suggest that abnormal pulmonary function is present in early stage IPD patients as evidenced by significant changes in PImax, PEmax, and P0.1. Most importantly, P0.1 may have the potential to assist with the identification of IPD in the early stage.
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Affiliation(s)
- Wei Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Lei Zhang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Ning Zhou
- Department of Respiratory, Tianjin Medical University General Hospital, Tianjin, China
| | - Enqiang Huang
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Qi Li
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Tongyu Wang
- Neurology Department of PKU Care CNOOC Hospital, Beijing, China
| | - Chunchao Ma
- Department of Neurology, Tianjin First Central Hospital, Tianjin, China
| | - Bin Li
- Department of Neurology, Tianjin Haibin People's Hospital, Tianjin, China
| | - Chen Li
- Department of Neurology, The Fifth Central Hospital of Tianjin, Binhai Hospital of Peking University, Tianjin, China
| | - Yanfen Du
- Department of Neurology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Jing Zhang
- Department of Neurology, Tianjin Third Central Hospital, Tianjin, China
| | - Xiaofeng Lei
- Department of Neurology, Tianjin Fourth Center Hospital, Tianjin, China
| | - Alysia Ross
- Department of Neuroscience, Carleton University, Ottawa, ON, Canada
| | - Hongyu Sun
- Department of Neuroscience, Carleton University, Ottawa, ON, Canada
| | - Xiaodong Zhu
- Department of Neurology, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
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19
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Gupta HV, Lyons KE, Pahwa R. Old Drugs, New Delivery Systems in Parkinson’s Disease. Drugs Aging 2019; 36:807-821. [DOI: 10.1007/s40266-019-00682-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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20
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Oliveira LM, Oliveira MA, Moriya HT, Moreira TS, Takakura AC. Respiratory disturbances in a mouse model of Parkinson's disease. Exp Physiol 2019; 104:729-739. [PMID: 30758090 DOI: 10.1113/ep087507] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/08/2019] [Indexed: 12/13/2022]
Abstract
NEW FINDINGS What is the central question of this study? Clinical reports have described and suggested central and peripheral respiratory abnormalities in Parkinson's disease (PD) patients; however, these reports have never addressed the occurrence of these abnormalities in an animal model. What is the main finding and its importance? A mouse model of PD has reduced neurokinin-1 receptor immunoreactivity in the pre-Bӧtzinger complex and Phox2b-expressing neurons in the retrotrapezoid nucleus. The PD mouse has impairments of respiratory frequency and the hypercapnic ventilatory response. Lung collagen deposition and ribcage stiffness appear in PD mice. ABSTRACT Parkinson's disease (PD) is a neurodegenerative motor disorder characterized by dopaminergic deficits in the brain. Parkinson's disease patients may experience shortness of breath, dyspnoea, breathing difficulties and pneumonia, which can be linked as a cause of morbidity and mortality of those patients. The aim of the present study was to clarify whether a mouse model of PD could develop central brainstem and lung respiratory abnormalities. Adult male C57BL/6 mice received bilateral injections of 6-hydroxydopamine (10 μg μl-1 ; 0.5 μl) or vehicle into the striatum. Ventilatory parameters were assessed in the 40 days after induction of PD, by whole-body plethysmography. In addition, measurements of respiratory input impedance (closed and opened thorax) were performed. 6-Hydroxydopamine reduced the number of tyrosine hydroxylase neurons in the substantia nigra pars compacta, the density of neurokinin-1 receptor immunoreactivity in the pre-Bӧtzinger complex and the number of Phox2b neurons in the retrotrapezoid nucleus. Physiological experiments revealed a reduction in resting respiratory frequency in PD animals, owing to an increase in expiratory time and a blunted hypercapnic ventilatory response. Measurements of respiratory input impedance showed that only PD animals with the thorax preserved had increased viscance, indicating that the ribcage could be stiff in this animal model of PD. Consistent with stiffened ribcage mechanics, abnormal collagen deposits in alveolar septa and airways were observed in PD animals. Our data showed that our mouse model of PD presented with neurodegeneration in respiratory brainstem centres and disruption of lung mechanical properties, suggesting that both central and peripheral deficiencies contribute to PD-related respiratory pathologies.
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Affiliation(s)
- Luiz M Oliveira
- Department of Pharmacology, Institute of Biomedical Science, University of São Paulo, São Paulo, SP, Brazil
| | - Maria A Oliveira
- Department of Pharmacology, Institute of Biomedical Science, University of São Paulo, São Paulo, SP, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, University of São Paulo, São Paulo, Brazil
| | - Thiago S Moreira
- Department of Physiology and Biophysics, Institute of Biomedical Science, University of São Paulo, São Paulo, SP, Brazil
| | - Ana C Takakura
- Department of Pharmacology, Institute of Biomedical Science, University of São Paulo, São Paulo, SP, Brazil
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Moon C, Smyth HDC, Watts AB, Williams RO. Delivery Technologies for Orally Inhaled Products: an Update. AAPS PharmSciTech 2019; 20:117. [PMID: 30783904 DOI: 10.1208/s12249-019-1314-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/18/2019] [Indexed: 12/22/2022] Open
Abstract
Orally inhaled products have well-known benefits. They allow for effective local administration of many drugs for the treatment of pulmonary disease, and they allow for rapid absorption and avoidance of first-pass metabolism of several systemically acting drugs. Several challenges remain, however, such as dosing limitations, low and variable deposition of the drug in the lungs, and high drug deposition in the oropharynx region. These challenges have stimulated the development of new delivery technologies. Both formulation improvements and new device technologies have been developed through an improved understanding of the mechanisms of aerosolization and lung deposition. These new advancements in formulations have enabled improved aerosolization by controlling particle properties such as density, size, shape, and surface energy. New device technologies emerging in the marketplace focus on minimizing patient errors, expanding the range of inhaled drugs, improving delivery efficiency, increasing dose consistency and dosage levels, and simplifying device operation. Many of these new technologies have the potential to improve patient compliance. This article reviews how new delivery technologies in the form of new formulations and new devices enhance orally inhaled products.
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Safety and efficacy of CVT-301 (levodopa inhalation powder) on motor function during off periods in patients with Parkinson's disease: a randomised, double-blind, placebo-controlled phase 3 trial. Lancet Neurol 2019; 18:145-154. [DOI: 10.1016/s1474-4422(18)30405-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 10/22/2018] [Accepted: 10/24/2018] [Indexed: 11/18/2022]
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23
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Stocchi F, Vacca L, Stirpe P, Torti M. Pharmacokinetic drug evaluation of CVT-301 for the treatment of Parkinson’s disease. Expert Opin Drug Metab Toxicol 2018; 14:1189-1195. [DOI: 10.1080/17425255.2018.1550483] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Fabrizio Stocchi
- Departement of Neurology, University and Institute for Research and Medical Care, San Raffaele Rome, Roma, Italy
| | - Laura Vacca
- Department of Neurorehabilitation Sciences, Casa Cura Policlinico (CCP), Milan, Italy
| | - Paola Stirpe
- Departement of Neurology, University and Institute for Research and Medical Care, San Raffaele Rome, Roma, Italy
| | - Margherita Torti
- Departement of Neurology, University and Institute for Research and Medical Care, San Raffaele Rome, Roma, Italy
- Departement of Neurology, Institute for Research and Medical Care, San Raffaele Cassino, Cassino (FR), Italy
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