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Park JS, Seo JH, Jeong MY, Yang IG, Kim JS, Kim JH, Ho MJ, Jin SG, Choi MK, Choi YS, Kang MJ. Carboxymethyl cellulose-based rotigotine nanocrystals-loaded hydrogel for increased transdermal delivery with alleviated skin irritation. Carbohydr Polym 2024; 338:122197. [PMID: 38763711 DOI: 10.1016/j.carbpol.2024.122197] [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: 01/11/2024] [Revised: 04/17/2024] [Accepted: 04/21/2024] [Indexed: 05/21/2024]
Abstract
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.
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Affiliation(s)
- Jun Soo Park
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea
| | - Jae Hee Seo
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea
| | - Min Young Jeong
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea
| | - In Gyu Yang
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea
| | - Ji Seong Kim
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea
| | - Jin Hwan Kim
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea
| | - Myoung Jin Ho
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea
| | - Sung Giu Jin
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea
| | - Min Koo Choi
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea
| | - Yong Seok Choi
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea.
| | - Myung Joo Kang
- College of Pharmacy, Dankook University, 119 Dandae-ro, Dongnam-gu, Cheonan, Chungnam 330-714, Republic of Korea.
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Hewer C, Richfield E, Halton C, Alty J. Transdermal Rotigotine at End-of-Life for Parkinson's Disease: Association With Measures of Distress. J Pain Symptom Manage 2024; 67:e121-e128. [PMID: 37838081 DOI: 10.1016/j.jpainsymman.2023.10.002] [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: 07/12/2023] [Revised: 09/27/2023] [Accepted: 10/03/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND End-of-life (EOL) care for Parkinson's disease (PD) can be challenging when oral medications are no longer tolerated. MEASURES To assess EOL prescribing for people with PD (PWP), focusing on rotigotine dosing and proxy measures of distress: benzodiazepine and opioid use. INTERVENTION A retrospective audit of patient records from PWP who died between January 2019 and May 2022 at the Royal Hobart Hospital (RHH), Australia, was conducted. Data was systematically collated on demographics, symptoms, levodopa equivalent daily dose (LEDD) and rotigotine, oral morphine equivalent (OME) and benzodiazepine doses in the last 72 hours of life . OUTCOMES Pain (72%), respiratory secretions (66%) and agitation (66%) were the most documented EOL symptoms. 83% (n = 52) of PWP were eligible for rotigotine and, of those, 13% (n = 7) received the correct dose, 38% (n = 20) a lower dose, 12% (n = 6) a higher dose and 37% (n = 19) did not receive any. Rotigotine dose was positively associated with total (P = 0.016) and PRN (P = 0.037) benzodiazepine dose. LEDD was positively associated with total benzodiazepine (P = 0.018) and total OME dose (P = 0.046). Contraindicated dopamine antagonists were prescribed for 43% of PWP and administered in 31% of those cases. CONCLUSIONS Rotigotine dose and admission LEDD were both associated with proxy measures of distress in the last 72 hours of life. This suggests cautious use of rotigotine at EOL. LEDD may help identify patients at risk of distress. Rates of inappropriate prescribing and symptom prevalence were high, indicating a need for further staff education to optimize the care of PWP.
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Affiliation(s)
- Claire Hewer
- Pallitative Care Department (C.H., C.H.), Royal Hobart Hospital, Hobart, Tasmania, Australia; Palliative Care Department (C.H.), Christchurch Hospital, Christchurch, New Zealand.
| | - Edward Richfield
- North Bristol NHS Trust (E.R.), Southmead Hospital, Westbury-on-Trym, Bristol, UK; Honorary Lecturer (E.R.), University of Bristol, Bristol, UK
| | - Carmen Halton
- Pallitative Care Department (C.H., C.H.), Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Jane Alty
- Wicking Dementia Research and Education Centre (J.A.), University of Tasmania, Hobart, Tasmania, Australia; Neurology Department (J.A.), Royal Hobart Hospital, Hobart, Tasmania, Australia
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Wilson EA, King-Oakley E, Richfield EW. Parkinson's disease: symptoms and medications at the end of life. BMJ Support Palliat Care 2024; 13:e912-e915. [PMID: 37463763 DOI: 10.1136/spcare-2023-004389] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/04/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVES People with Parkinson's disease (PwP) have a high palliative symptom burden throughout their disease course, equivalent to advanced malignancy. We aim to establish trends in symptom frequency and prescribing in the 72 hours prior to death for PwP. METHODS Retrospective case note review of PwP who died between February 2019 and September 2020. RESULTS 51 patients were included. 60.78% of patients (n=31) had agitation and 58.82% (n=30) had pain in the final 72 hours. Patients with cognitive impairment were 4.67 times more likely to experience agitation (p=0.035) compared with those without, with higher total midazolam doses (29.18 mg vs 11.4 mg, p=0.21). Terminal motor symptoms were recorded in three patients. 28.57% of patients received the recommended dose of rotigotine for dopaminergic therapy. CONCLUSIONS PwP have a significant symptom burden at the end of life (EOL) with levels of terminal agitation at the higher end of those expected in the general population. There was a trend towards higher doses of sedation, rather than analgesia, in people with coexistent cognitive impairment.Terminal stiffness, despite being seldom documented in the literature, is an important although infrequent symptom.Rotigotine use at EOL remains commonplace and better understanding of its effect and dosing is required.
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Béreau M, Giffard M, Clairet AL, Degenne G, Tatu L, Richfield E, Magnin E, Vérin M, Auffret M. Terminal Care in Parkinson's Disease: Real-Life Use of Continuous Subcutaneous Apomorphine Infusion to Improve Patient Comfort. JOURNAL OF PARKINSON'S DISEASE 2024; 14:209-219. [PMID: 38217611 PMCID: PMC10836545 DOI: 10.3233/jpd-230201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND There are currently no recommendations on the therapeutic management of Parkinson's disease (PD) patients at the end of life. OBJECTIVE To describe a cohort of patients with PD who benefited from continuous subcutaneous apomorphine infusion (CSAI) initiation at the end of their life as comfort care. METHODS This real-life cohort includes 14 PD patients, who benefited from 24-h, low-dose CSAI (0.5-3 mg/h) in the context of terminal care. Patient's comfort (pain, rigidity, and/or ability to communicate) and occurrence of CSAI-related side-effects (nausea/vomiting, cutaneous and behavioral manifestations) were evaluated based on medical records. RESULTS All patients (age 62-94 years, disease duration 2-32 years) presented with late-stage PD and a compromised oral route. Treatment lasted from a few hours to 39 days. CSAI led to substantial functional improvement, with a good safety profile. Overall clinical comfort was deemed improved by the medical team, the patient, and/or caregivers. CONCLUSIONS CSAI might be a promising approach in PD terminal care, as it reduces motor symptoms and overall discomfort, with an apparent good safety profile. Use of the apomorphine pen, sublingual film or a classic syringe pump might be considered when apomorphine pumps are not available. Larger observational cohorts and randomized controlled trials are needed to establish the efficacy and tolerability of apomorphine in the context of terminal care and more broadly, in an advance care planning perspective.
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Affiliation(s)
- Matthieu Béreau
- Neurology Department, CHU Besançon, Besançon, France
- Université de Franche-Comté, UR LINC, Besançon, France
| | - Mathilde Giffard
- Mobile Palliative Care Team, CHU Besançon, Besançon, France
- Inserm CIC 1431, CHU Besançon, Besançon, France
| | - Anne-Laure Clairet
- Department of Pharmacy, University Hospital of Besançon, Besançon, France
| | | | - Laurent Tatu
- Neurology Clinical Electrophysiology Department, CHU Besançon, Besançon, France
- Laboratoire d’Anatomie, Université de Franche-Comté, Besançon, France
| | - Edward Richfield
- North Bristol NHS Trust, Department of Geriatrics, Southmead Road, Southmead, Bristol, UK
| | - Eloi Magnin
- Neurology Department, CHU Besançon, Besançon, France
- Université de Franche-Comté, UR LINC, Besançon, France
- Centre Neurodéveloppemental ⪡Hors Normes⪢, AFTC, Besançon, France
| | - Marc Vérin
- Institut des Neurosciences Cliniques de Rennes (INCR), Rennes, France
- Behavior & Basal Ganglia Research Unit, CIC-IT, CIC1414, Pontchaillou University Hospital, & University of Rennes, Rennes, France
- Neurology Department, Movement Disorders Unit, Pontchaillou University Hospital, Rennes, France
| | - Manon Auffret
- Institut des Neurosciences Cliniques de Rennes (INCR), Rennes, France
- Behavior & Basal Ganglia Research Unit, CIC-IT, CIC1414, Pontchaillou University Hospital, & University of Rennes, Rennes, France
- France Développement Electronique (FDE), Monswiller, France
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Wilson E, Lovell N, Richfield E. Hiccups at the End of Life in Parkinson's Disease: A Case Report. J Pain Symptom Manage 2023; 66:e525-e527. [PMID: 37451350 DOI: 10.1016/j.jpainsymman.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Elisabeth Wilson
- Medicine for Older People (E.W., E.R.), North Bristol NHS Trust, Bristol, United Kingdom.
| | - Natasha Lovell
- Specialist Palliative Care (N.L.), North Bristol NHS Trust, Bristol, United Kingdom
| | - Edward Richfield
- Medicine for Older People (E.W., E.R.), North Bristol NHS Trust, Bristol, United Kingdom
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Bhansali S, Assaedi E, Yu JRT, Mandava N, Sonneborn C, Hogue O, Walter BL, Samala RV, Margolius A. End of life care of hospitalized patients with Parkinson disease: a retrospective analysis and brief review. Front Aging Neurosci 2023; 15:1265156. [PMID: 37744391 PMCID: PMC10511646 DOI: 10.3389/fnagi.2023.1265156] [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: 07/22/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Background Towards the end of life (EOL), persons with parkinsonism (PwP) have complex needs and can present with unique palliative care (PC) challenges. There are no widely accepted guidelines to aid neurologists, hospitalists, or PC clinicians in managing the symptoms of PwP at EOL. We examined a population of PwP at EOL, aiming to describe trends of in-hospital management and utilization of PC services. Methods All PwP admitted to two hospitals during 2018 (N = 727) were examined retrospectively, assessing those who died in hospital or were discharged with hospice (EOL group, N = 35) and comparing them to the main cohort. Their demographics, clinical data, engagement of multidisciplinary and palliative services, code status changes, invasive care, frequency of admissions, and medication administration were assessed. Results Among the EOL group, 8 expired in hospital, and 27 were discharged to hospice. Forty-six percent of EOL patients received a PC consultation during their admission. The median interval from admission to death was 37 days. Seventy-seven percent had a full code status on admission. Compared to hospice patients, those who expired in hospital had higher rates of invasive procedures and intensive care unit transfers (41% vs. 75%, in both variables), and lower rates of PC involvement (52% vs. 25%). The transition of code status change for the EOL group from Full code to Do Not Resuscitate (DNR) occurred at a median 4-5 days from admission. For patients that passed in the hospital, the median days from transition of code status to death was 0(IQR 0-1). Levodopa dose deviations were frequent in both EOL and non-EOL group, but contraindicated medications were infrequently administered (11% in EOL group vs. 9% in non-EOL group). Conclusion Our data suggest a low utilization of PC services and delayed discussions of goals of care. More work is needed to raise awareness of inpatient teams managing PwP regarding the unique but common challenges facing PwP with advanced disease. A brief narrative review summarizing the suggested management of symptoms common to hospitalized PwP near EOL is provided.
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Affiliation(s)
- Sakhi Bhansali
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Ekhlas Assaedi
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Jeryl Ritzi T. Yu
- Institute for Neurosciences, St. Luke’s Medical Center, Quezon City, Philippines
- University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines
| | - Nymisha Mandava
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Claire Sonneborn
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Olivia Hogue
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | | | - Renato V. Samala
- Department of Palliative and Supportive Care, Cleveland Clinic, Cleveland, OH, United States
| | - Adam Margolius
- Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
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Kim W, Watt CL, Enright P, Sikora L, Zwicker J. Management of Motor Symptoms for Patients with Advanced Parkinson's Disease without Safe Oral Access: A Scoping Review. J Palliat Med 2023; 26:131-141. [PMID: 36126303 DOI: 10.1089/jpm.2022.0193] [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: 01/11/2023] Open
Abstract
Context: Parkinson's disease (PD) is the second most common neurodegenerative disorder worldwide. Oral medications for control of motor symptoms are the mainstay of treatment. However, as the disease progresses, patients with PD may develop dysphagia that prohibits them from safely taking oral medications. Currently there are no clinical guidelines for managing distressing motor symptoms in patients with PD and severe dysphagia, which can therefore be quite challenging. Objectives: To provide an exhaustive summary of current literature on pharmacological interventions for patients with PD who do not have safe oral access in managing distressing motor symptoms. Indication, route, doses, frequency, outcome, and adverse effects will be discussed. Methods: A scoping review using Medline, Embase, CENTRAL, CINAHL, AgeLine, and PsycINFO databases (1946-2021) was conducted. Articles examining patients with PD and dysphagia who are eligible to receive palliative care or at end of life were included. Studies that included patients who were also on oral PD medications or received device-aided therapy were excluded from this review. Results: A total of 3821 articles were screened for title and abstract, 259 were selected for full-text review, and 20 articles were selected for data extraction. These included five case reports, one retrospective cohort study, one book chapter, and 13 narrative reviews. There are very few articles addressing the issue of treatment of patients with advanced PD who are unable to take oral medications. Although rotigotine patch and apormorphine injections are most frequently recommended, there are no clinical trials in this patient population to support those recommendations. Conclusion: This study highlights a need for further research examining the efficacy and dosing of nonoral medications in advanced PD with dysphagia.
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Affiliation(s)
- WooJin Kim
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine L Watt
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paula Enright
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Jocelyn Zwicker
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Hindmarsh J, Hindmarsh S, Lee M. Idiopathic Parkinson's Disease at the End of Life: A Retrospective Evaluation of Symptom Prevalence, Pharmacological Symptom Management and Transdermal Rotigotine Dosing. Clin Drug Investig 2021; 41:675-683. [PMID: 34213758 DOI: 10.1007/s40261-021-01054-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Distressing symptoms are prevalent in patients with idiopathic Parkinson's disease, yet little is known about symptom burden and subsequent pharmacological management at the end of life. Additionally, when oral administration of antiparkinsonian medications is no longer possible in dying patients, it is becoming common place to initiate transdermal rotigotine, despite a paucity of evidence to guide dosing. OBJECTIVES To assess: (1) symptom prevalence from the use of anticipatory medicines in patients with idiopathic Parkinson's disease, (2) the prescribing of antiparkinsonian medication at the end of life; and (3) the accuracy of conversion from oral antiparkinsonian medicines to transdermal rotigotine and any associations between rotigotine dosing and end-of-life symptoms. METHODS A retrospective case review was performed. One hundred consecutive patients with idiopathic Parkinson's disease who died during an inpatient admission at a UK teaching hospital were assessed. RESULTS The most prevalent terminal symptoms were excess respiratory secretions (58%), pain (52%), agitation (51%) and fever (23%). The majority of patients were converted to transdermal rotigotine (90%). Patients converted to a higher than equivalent dose of rotigotine were more likely to be agitated (p < 0.05), whilst those converted to a lower than equivalent dose were less likely to develop excess respiratory secretions (p < 0.05). The prevalence of pain did not differ according to rotigotine dosing. CONCLUSIONS This study highlights for the first time use of anticipatory medications at the end of life in patients with idiopathic Parkinson's disease and the prevalence of terminal symptoms. It also demonstrates the widespread use of rotigotine patches, and that lower than equivalent doses may be better tolerated.
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Affiliation(s)
- Jonathan Hindmarsh
- Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, UK.
- Department of Pharmacy, Sunderland Royal Hospital, South Tyneside and Sunderland Foundation Trust, Kayll Road, Sunderland, SR4 7TP, UK.
| | - Sharlene Hindmarsh
- Department of Pharmacy, Sunderland Royal Hospital, South Tyneside and Sunderland Foundation Trust, Kayll Road, Sunderland, SR4 7TP, UK
| | - Mark Lee
- Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, UK
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