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Witt K, Levin J, van Eimeren T, Hasan A, Ebersbach G. Diagnostics and treatment of impulse control disorders, psychosis and delirium: systemic review-based recommendations - guideline "Parkinson's disease" of the German Society of Neurology. J Neurol 2024:10.1007/s00415-024-12576-x. [PMID: 39046524 DOI: 10.1007/s00415-024-12576-x] [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: 05/23/2024] [Revised: 07/05/2024] [Accepted: 07/07/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND AND OBJECTIVE Impulse control disorders (ICD), psychosis and delirium are part of the spectrum of behavioural changes associated with Parkinson's disease (PD). The diagnostic and therapeutic management of these rather complex neuropsychiatric conditions has been updated in the clinical guideline by the German Society of Neurology (DGN). METHODS Recommendations are based on a systematic literature reviews, other relevant guidelines and expert opinion. RESULTS Patients receiving dopamine agonists (DA) therapy should be informed about the symptoms and risks of an ICD and should be routinely screened for ICD symptoms. In the presence of an ICD, DA should be reduced or discontinued and psychotherapeutic treatment may be considered. Non-oral therapies (levodopa/carbidopa intestinal gel infusion or deep brain stimulation) may also be an option for appropriate candidates. Psychosis in PD often has a gradual onset. Cognitive and affective disorders, psychiatric and medical comorbidities as well as polypharmacy are risk factors for a psychosis. Non-pharmacological treatments should be implemented as soon as possible and anti-parkinsonian medications should be adjusted/reduced if feasible. For psychosis associated with PD, quetiapine or clozapine should be used on an as-needed basis and for as short a time as is necessary, with safety monitoring. Delirium in PD may be underdiagnosed due to an overlap with chronic neuropsychiatric features of PD. Although transient by definition, delirium in PD can lead to permanent cognitive decline, motor impairment and increased mortality. Management of delirium includes pharmacological and non-pharmacological interventions. CONCLUSION The updated guideline encompasses the evidence-based diagnostic, non-pharmacological and pharmacological management of ICD, psychosis and delirium in PD.
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Affiliation(s)
- Karsten Witt
- Department of Neurology, School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Marienstrasse 15, 26121, Oldenburg, Germany.
- University Clinic of Neurology, Evangelical Hospital, Oldenburg, Germany.
- Center of Neurosensory Sciences, University of Oldenburg, Oldenburg, Germany.
| | - Johannes Levin
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- German Center for Neurodegenerative Diseases, Site Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | | | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- DZPG (German Center for Mental Health), Partner Site München/Augsburg, Augsburg, Germany
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Danics L, Abbas AA, Kis B, Pircs K. Fountain of youth—Targeting autophagy in aging. Front Aging Neurosci 2023; 15:1125739. [PMID: 37065462 PMCID: PMC10090449 DOI: 10.3389/fnagi.2023.1125739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
As our society ages inexorably, geroscience and research focusing on healthy aging is becoming increasingly urgent. Macroautophagy (referred to as autophagy), a highly conserved process of cellular clearance and rejuvenation has attracted much attention due to its universal role in organismal life and death. Growing evidence points to autophagy process as being one of the key players in the determination of lifespan and health. Autophagy inducing interventions show significant improvement in organismal lifespan demonstrated in several experimental models. In line with this, preclinical models of age-related neurodegenerative diseases demonstrate pathology modulating effect of autophagy induction, implicating its potential to treat such disorders. In humans this specific process seems to be more complex. Recent clinical trials of drugs targeting autophagy point out some beneficial effects for clinical use, although with limited effectiveness, while others fail to show any significant improvement. We propose that using more human-relevant preclinical models for testing drug efficacy would significantly improve clinical trial outcomes. Lastly, the review discusses the available cellular reprogramming techniques used to model neuronal autophagy and neurodegeneration while exploring the existing evidence of autophagy’s role in aging and pathogenesis in human-derived in vitro models such as embryonic stem cells (ESCs), induced pluripotent stem cell derived neurons (iPSC-neurons) or induced neurons (iNs).
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Affiliation(s)
- Lea Danics
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
- Hungarian Centre of Excellence for Molecular Medicine - Semmelweis University (HCEMM-SU), Neurobiology and Neurodegenerative Diseases Research Group, Budapest, Hungary
- Eötvös Loránd Research Network and Semmelweis University (ELKH-SU), Cerebrovascular and Neurocognitive Disorders Research Group, Budapest, Hungary
| | - Anna Anoir Abbas
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
- Hungarian Centre of Excellence for Molecular Medicine - Semmelweis University (HCEMM-SU), Neurobiology and Neurodegenerative Diseases Research Group, Budapest, Hungary
| | - Balázs Kis
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
- Hungarian Centre of Excellence for Molecular Medicine - Semmelweis University (HCEMM-SU), Neurobiology and Neurodegenerative Diseases Research Group, Budapest, Hungary
| | - Karolina Pircs
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
- Hungarian Centre of Excellence for Molecular Medicine - Semmelweis University (HCEMM-SU), Neurobiology and Neurodegenerative Diseases Research Group, Budapest, Hungary
- Laboratory of Molecular Neurogenetics, Department of Experimental Medical Science, Wallenberg Neuroscience Center and Lund Stem Cell Center, Lund University, Lund, Sweden
- *Correspondence: Karolina Pircs,
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Rajagopalan K, Rashid N, Kumar S, Doshi D. Health care resource utilization patterns among patients with Parkinson's disease psychosis: analysis of Medicare beneficiaries treated with pimavanserin or other-atypical antipsychotics. J Med Econ 2023; 26:34-42. [PMID: 36444507 DOI: 10.1080/13696998.2022.2152600] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pimavanserin (PIM) is the only FDA-approved atypical antipsychotic (AAP) for hallucinations and delusions associated with Parkinson's disease psychosis (PDP). Comparative real-world analyses demonstrating its benefits are needed. OBJECTIVES To evaluate health care resource utilization (HCRU) outcomes among PDP patients treated with PIM vs. other-AAPs. METHODS Retrospective cohort analysis of Parts A, B, and D claims from 100% Medicare sample from 01 January 2013-31 December 2019 was conducted. PDP Patients initiating (i.e. index date) continuous monotherapy (PIM vs. other-AAPs) for ≥12-months during 01 January 2014-31 December 2018 without 12-months pre-index AAP use were selected after 1:1 propensity score matching (PSM) on 31 variables (sex, race, region, age, and 27 Elixhauser comorbidities). HCRU outcomes included: annual all-cause and psychiatric hospitalization (short-term stay, long-term stay, and SNF-stay [skilled nursing facility]) rates, annual all-cause and psychiatric-ER visit rates, mean per-patient-per-year (PPPY) hospitalizations, and average length of stay (ALOS). PIM and other-AAPs were compared using generalized linear models (GLM) controlled for demographic characteristics, comorbidities, coexisting-dementia, and coexisting insomnia. RESULTS Of 12,164 PDP patients, 48.41% (n = 5,889) were female, and mean age was 77 (±8.14) years. Among 1:1 matched patients (n = 842 in each), 37.8% (n = 319) on PIM vs. 49.8% (n = 420) on other-AAPs (p < .05) reported ≥1 all-cause hospitalizations, respectively. Specifically, short-term and SNF-stay among PIM patients vs. other-AAPs were: 34% (n = 286) vs. 46.2% (n = 389) and 20.2% (n = 170) vs. 31.8% (n = 267) (p < .05), respectively. Similarly, 9.6% (n = 81) of PIM vs. 14.6% (n = 123) of other-AAPs patients had ≥1 psychiatric hospitalization (p < .05). Furthermore, ≥1 all-cause and psychiatric ER visit among PIM vs. other-AAPs were 61.6% (n = 519) vs. 69.4% (n = 584) and 5.2% (n = 43) vs. 10.2% (n = 86) (p < .05), respectively. PIM also had significantly lower ALOS, and mean PPPY short-term hospitalization and SNF-stays. CONCLUSIONS In this analysis of PDP patients, PIM monotherapy resulted in nearly 12% and 7% lower all-cause hospitalizations and ER visits vs. other-AAPs.
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Rajagopalan K, May D, Worz C, Hernandez S, Doshi D. Role of Pimavanserin Treatment-Continuity on Discharge From Long-term Care: Assessing the Quality of Antipsychotic Medication Review. Sr Care Pharm 2022; 37:510-522. [DOI: 10.4140/tcp.n.2022.510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: To investigate the role of (1) antipsychotic medication review (AP-MR) documentation quality of Minimum Data Set 3.0 (MDS) surveys, and (2) treatment-continuity on discharge-to-community and clinical outcomes among long-term care (LTC) residents treated with pimavanserin.
Design, Setting, and Participants: A retrospective cohort analysis of Parts A, B, and D claims from Medicare 100% sample merged with MDS data from June 2016 through December 2018 was conducted. Residents with more than 100-day LTC stay and 1 pimavanserin prescription or more
with completed antipsychotic-use MDS question were selected. AP-MR documentation quality (ie, gradual dose reduction [GDR] attempts, clinical contraindication to GDR), discharge-to-community, and clinical outcomes (eg, falls, fractures) were obtained from MDS. Treatment-continuity was assessed
from Part D claims. Data Analysis: Descriptive statistics (frequencies, proportions, Chi-square tests, and means) and adjusted logistic regressions (ORs with 95% CIs reported association between pimavanserin treatment-continuity and discharge-to-community. Results:
Of 4,021 eligible residents, 29% (n = 1,182) attempted a GDR per AP-MR MDS documentation. Approximately 41% (n = 1,665) had documentation showing GDR was clinically contraindicated, yet 39% (n = 645) still attempted GDR. While overall discharge-to-community rates were low, it was significantly
higher (P < 0.05) among LTC residents continuing (14.94%; n = 380/2,546) versus discontinuing (11.84%; n = 171/1,444) pimavanserin. OR for treatment-continuity was 1.96, 95% CI 1.50-2.55. Residents continuing pimavanserin had lower incidents of falls (2.8% vs 9.4%), hip fractures
(0.29% vs 0.69%), and pelvic/femur fractures (0% vs 0.92%) versus those residents who discontinued it. Conclusions: Among LTC-stay residents, high discordance between GDR rates and AP-MR MDS documentation quality was observed. Pimvanserin treatment-continuity showed greater
likelihood of discharge-to-community; continued documentation training can ensure appropriate antipsychotic use with a balanced benefit:risk profile.
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Affiliation(s)
| | - Damian May
- 2Medical Affairs, Acadia Pharmaceuticals, San Diego, California
| | - Chad Worz
- 3The American Society of Consultant Pharmacists, Alexandria, Virginia
| | | | - Dilesh Doshi
- 2Medical Affairs, Acadia Pharmaceuticals, San Diego, California
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Rissardo JP, Durante Í, Sharon I, Fornari Caprara AL. Pimavanserin and Parkinson's Disease Psychosis: A Narrative Review. Brain Sci 2022; 12:1286. [PMID: 36291220 PMCID: PMC9599742 DOI: 10.3390/brainsci12101286] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 10/18/2023] Open
Abstract
Pimavanserin (PMV) is the first approved drug for treating hallucinations and delusions in Parkinson's disease (PD) psychosis. Psychosis is one of the leading causes of nursing home placement in people with PD. Furthermore, hallucinations are a more frequent cause of institutionalization than motor disability or dementia related to PD. The management of PD psychosis involves antipsychotic medications. Most of the drugs in this class directly block dopamine D2 receptors, leading to significantly worsening motor symptoms in patients with PD. The most commonly used medications for managing PD psychosis are quetiapine, clozapine, and PMV. This literature review aims to study pimavanserin's history, mechanism, clinical trials, and post-marketing experience. PMV is a potent 5-HT2A receptor antagonist/inverse agonist. Moreover, this drug can interact with 5-HT2C receptors. We calculated some physicochemical descriptors and pharmacokinetic properties of PMV. Eight clinical trials of PMV and PD psychosis are registered on ClinicalTrials.gov. Only four of them have complete results already published. Meta-analytic results showed that PMV efficacy is inferior to clozapine. However, PMV has a significantly lower number of side-effects for managing psychosis in PD. Medicare database assessment revealed 35% lower mortality with PMV compared to other atypical antipsychotics. Moreover, sensitive statistical analysis demonstrated that PMV is a protective factor for the risk of falls in individuals with PD.
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Affiliation(s)
- Jamir Pitton Rissardo
- Medicine Department, Federal University of Santa Maria, Santa Maria 97105-900, Brazil
| | - Ícaro Durante
- Department of Medicine, Federal University of Fronteira Sul, Passo Fundo 99010-121, Brazil
| | - Idan Sharon
- NewYork-Presbyterian Brooklyn Methodist Hospital, New York, NY 11215, USA
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Halhouli O, Zhang Q, Aldridge GM. Caring for patients with cognitive dysfunction, fluctuations and dementia caused by Parkinson's disease. PROGRESS IN BRAIN RESEARCH 2022; 269:407-434. [PMID: 35248204 DOI: 10.1016/bs.pbr.2022.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cognitive dysfunction is one of the most prevalent non-motor symptoms in patients with Parkinson's disease (PD). While it tends to worsen in the later stages of disease, it can occur at any time, with 15-20% of patients exhibiting cognitive deficits at diagnosis (Aarsland et al., 2010; Goldman and Sieg, 2020). The characteristic features of cognitive dysfunction include impairment in executive function, visuospatial abilities, and attention, which vary in severity from subtle impairment to overt dementia (Martinez-Horta and Kulisevsky, 2019). To complicate matters, cognitive dysfunction is prone to fluctuate in PD patients, impacting diagnosis and the ability to assess progression and decision-making capacity. The diagnosis of cognitive impairment or dementia has a huge impact on patient independence, quality of life, life expectancy and caregiver burden (Corallo et al., 2017; Lawson et al., 2016; Leroi et al., 2012). It is therefore essential that physicians caring for patients with PD provide education, screening and treatment for this aspect of the disease. In this chapter, we provide a practical guide for the assessment and management of various degrees of cognitive dysfunction in patients with PD by approaching the disease at different stages. We address risk factors for cognitive dysfunction, prevention strategies prior to making the diagnosis, available tools for screening. Lastly, we review aspects of care, management and considerations, including decision-making capacity, that occur after the patient has been diagnosed with cognitive dysfunction or dementia.
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Affiliation(s)
- Oday Halhouli
- University of Iowa, Department of Neurology, Iowa City, IA, United States
| | - Qiang Zhang
- University of Iowa, Department of Neurology, Iowa City, IA, United States
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Mansuri Z, Reddy A, Vadukapuram R, Trivedi C, Amara A. Pimavanserin in the Treatment of Parkinson's Disease Psychosis: Meta-analysis and Meta-regression of Randomized Clinical Trials. INNOVATIONS IN CLINICAL NEUROSCIENCE 2022; 19:46-51. [PMID: 35382074 PMCID: PMC8970241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Up to 60 percent of patients with Parkinson's disease (PD) develop Parkinson's disease psychosis (PDP). PDP is associated with a significant economic burden. The management of PDP has been divided into two approaches-one focuses on decreasing the doses of anti-Parkinsonian medications and the other involves prescribing atypical antipsychotics. Of these atypical antipsychotics, pimavanserin is United States (US) Food and Drug Administration (FDA)-approved specifically for the treatment of PDP. OBJECTIVE The goal was to evaluate the safety and efficacy of pimavanserin in the treatment of PDP based on data from randomized clinical trials. METHODS All the articles, which assessed pimavanserin's effect on the treatment of PDP, were retrieved from Google Scholar, PubMed, and abstracts from annual scientific sessions. The data on dose, therapy duration, patient numbers, and study duration were collected. These data were analyzed with random effect modeling using the inverse variance method and the Mantel-Haenszel method. RESULTS Four studies comparing pimavanserin to a placebo provided data on 680 patients (263 placebo, 417 pimavanserin). Treatment with pimavanserin was associated with a significant reduction in scores using the Scale of Assessment of Positive Symptoms, Hallucinations, and Delusion (SAPS-H+D) (mean difference [MD]: -1.55 [-2.71, -0.379], p=0.009). The groups had similar composite scores for Unified Parkinson's Disease Rating Scale II and III (UPDRS II and III) (MD: 0.093 [-1.28, 1.46], p=0.89). Interestingly, pimavanserin was protective against orthostatic hypotension (risk ratio: 0.33 [0.30, 0.37], p<0.001). All other adverse events were similarly distributed across both groups. CONCLUSION There was a significant improvement in psychosis symptoms in patients with PD who took pimavanserin. Pimavanserin was also shown to be protective against orthostatic hypotension.
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Affiliation(s)
- Zeeshan Mansuri
- Dr. Mansuri is with the Department of Psychiatry, Boston Children's Hospital/Harvard Medical School in Boston, Massachusetts
| | - Abhishek Reddy
- Dr. Reddy is with the Department of Psychiatry, Virginia Tech Carilion School of Medicine in Roanoke, Virginia
| | - Ramu Vadukapuram
- Dr. Vadukapuram is with the Department of Psychiatry, Icahn School of Medicine at Mount Sinai in New York, New York
| | - Chintan Trivedi
- Dr. Trivedi is with St. David Medical Center in Austin, Texas
| | - Amy Amara
- Dr. Amara is with the Department of Neurology at the University of Alabama at Birmingham in Birmingham, Alabama
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Segal GS, Xie SJ, Paracha SUR, Grossberg GT. Psychosis in Parkinson's Disease: Current Treatment Options and Impact on Patients and Caregivers. J Geriatr Psychiatry Neurol 2021; 34:274-279. [PMID: 34219522 DOI: 10.1177/08919887211018280] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Parkinson's disease (PD) is the second most common neurodegenerative disease seen in older adults after Alzheimer's disease, with increasing prevalence worldwide. Parkinson's disease psychosis (PDP) is a common, non-motor feature of PD, which increases caregiver stress and is a risk-factor for nursing home placement. In this paper we review PDP epidemiology, features, diagnosis, and treatment. PDP most often presents with sequential development of minor and then increasingly complex visual hallucinations mediated by dopaminergic-serotonergic interactions activating the mesolimbic pathway, with contributions from other structures and neurotransmitters. Appropriate evaluation of differential diagnoses for psychosis is vital before diagnosing PDP. Initial treatment should involve non-pharmacologic approaches. If these are unsuccessful and PDP symptoms significantly impact the patient's and or their caregivers' quality of life and functions, then pharmacotherapy is indicated. Pimavanserin is a recently FDA-approved pharmacologic treatment for PDP with a better profile of balanced effectiveness and safety compared to previous use of atypical antipsychotics. Early diagnosis and safer, more effective treatments for PDP should help reduce caregiver burden and enable caregivers to continue to provide care at home versus institutionalization.
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Affiliation(s)
- Gilad S Segal
- 7547Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Sophie J Xie
- 7547Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Saif-Ur-Rahman Paracha
- Department of Psychiatry and Behavioral Neuroscience, 7547Saint Louis University School of Medicine, MO, USA
| | - George T Grossberg
- Samuel W. Fordyce Professor and Director of Geriatric Psychiatry, Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, MO, USA
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Abstract
Dementia is a syndrome characterized by a gradually progressive course that spans a continuum from preclinical symptoms to major impairment in two or more cognitive domains with functional decline. In this review, the author examines some of the more common dementia syndromes from among dozens of different diseases. Findings show that as the U.S. population continues to age, the number of Americans with dementia is expected to rise drastically over the next several decades. This upsurge will contribute to increased health care costs and will have a significant public health impact. Neurodegenerative disorders such as Alzheimer's disease, frontotemporal degeneration, and alpha-synucleinopathies (e.g., Lewy body disease and Parkinson's disease) are some of the more prevalent causes for dementia. In recent years, advancements in neuroimaging, understanding of genetic contributions and pathological changes, and the development of novel biomarkers have fueled clinical understanding of these disorders. However, substantial disease-modifying therapies are still lagging. The advent of future interventions hinges on the ability to discern the distinct clinico-pathologic profiles of the various dementia syndromes and to identify reliable biomarkers for utilization in clinical trials.
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Affiliation(s)
- Kristin C Jones
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston
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Livezey S, Shah NB, McCormick R, DeClercq J, Choi L, Zuckerman AD. Specialty pharmacist integration into an outpatient neurology clinic improves pimavanserin access. Ment Health Clin 2021; 11:187-193. [PMID: 34026394 PMCID: PMC8120983 DOI: 10.9740/mhc.2021.05.187] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Introduction Access to pimavanserin, the only Parkinson disease–related psychosis treatment approved by the FDA, is restricted by insurance requirements, a limited distribution network, and high costs. Following initiation, patients require monitoring for safety and effectiveness. The primary objective of this study was to evaluate impact of specialty pharmacist (SP) integration on time to insurance approval. Additionally, we describe a pharmacist-led monitoring program. Methods This was a single-center, retrospective study of adults prescribed pimavanserin by the neurology clinic from June 2016 to June 2018. Patients receiving pimavanserin externally or through clinical trials were excluded. Pre- (June 2016 to December 2016) and post-SP integration (January 2017 to June 2018) periods were assessed. Proportional odds logistic regression was performed to test association of approval time with patient characteristics (age, gender, insurance type) postintegration. Interventions were categorized as clinical care, care coordination, management of adverse event, or adherence. Results We included 94 patients (32 preintegration, 62 postintegration), 80% male (n = 75) and 96% white (n = 90) with a mean age of 73 years. Median time to approval was 22 days preintegration and 3 days postintegration. Higher rates of approval (81% vs 95%) and initiation (78% vs 94%) were observed postintegration. Proportional odds logistic regression suggested patients with commercial insurance were likely to have longer time to approval compared with patients with Medicare/Medicaid (odds ratio 7.1; 95% confidence interval: 1.9, 26.7; P = .004). Most interventions were clinical (51%, n = 47) or care coordination (42%, n = 39). Conclusion Median time to approval decreased postintegration. The SP performed valuable monitoring and interventions.
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Affiliation(s)
- Sabrina Livezey
- Clinical Pharmacist, Neurology, Vanderbilt University Medical Center, Nashville, Tennessee,
| | - Nisha B Shah
- Pharmacist, Health Outcomes and Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert McCormick
- Student Researcher, University of Tennessee Health Science Center, College of Pharmacy, Nashville, Tennessee
| | - Josh DeClercq
- Biostatistician, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leena Choi
- Biostatistician, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Autumn D Zuckerman
- Program Director, Health Outcomes and Research, Vanderbilt University Medical Center, Nashville, Tennessee
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Billnitzer A, Jankovic J. Pilot Study to Evaluate Pimavanserin for the Treatment of Motor and Behavioral Symptoms of Tourette Syndrome. Mov Disord Clin Pract 2021; 8:694-700. [PMID: 34307741 DOI: 10.1002/mdc3.13207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/04/2021] [Accepted: 03/15/2021] [Indexed: 12/24/2022] Open
Abstract
Background Pimavanserin is a serotonin 2A receptor inverse agonist and antagonist used for the treatment of hallucinations and delusions in Parkinson's disease psychosis. Numerous studies support a modulatory role of serotonin in Tourette syndrome (TS). Objectives To determine whether or not pimavanserin affects TS symptoms. Methods In this open-label study of TS adult patients, pimavanserin was titrated to 34 mg/day over 1 week and continued for an additional 7 weeks followed by a 2-week washout. Tic severity, the primary outcome measure, was assessed by the Yale Global Tic Severity Scale Total Tic Severity score (YGTSS-TTS). Secondary outcome measures included changes in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Tourette Syndrome Clinical Global Impression of Change (TS-CGIC), the Tourette Syndrome-Patient Global Impression of Impact (TS-PGII), and the Gilles de la Tourette Syndrome - Quality of Life scale (GTS-QOL). Results We enrolled 12 patients, but 2 dropped out after week 2 due to non-serious side effects. In the 10 patients, mean (standard deviation (SD)) age 34 (12.9) who completed the study the mean (SD) baseline YGTSS-TTS was 34 (9.3). This decreased by 3.6 (4.9) points at week 8, a 12% reduction in tic severity (P = 0.03). This improvement is small and may not be clinically important. Significant improvement was noted in the TS-CGIC, TS-PGII and GTS-QO. No serious adverse events were reported. Conclusions The results of this study suggest that pimavanserin is safe and associated with improvement in motor and non-motor TS symptoms. These findings warrant further study by a larger, placebo-controlled, trial.
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Affiliation(s)
- Andrew Billnitzer
- Department of Neurology Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine Houston Texas USA
| | - Joseph Jankovic
- Department of Neurology Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine Houston Texas USA
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Pimavanserin Treatment for Parkinson's Disease Psychosis in Clinical Practice. PARKINSONS DISEASE 2021; 2021:2603641. [PMID: 33489083 PMCID: PMC7801085 DOI: 10.1155/2021/2603641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 01/04/2023]
Abstract
Background Parkinson's disease psychosis (PDP) is a common, nonmotor symptom of Parkinson's disease (PD), which may affect up to 60% of patients and is associated with impaired quality of life, increased healthcare costs, and nursing home placement, among other adverse outcomes. Characteristic symptoms of PDP include illusions; visual, auditory, tactile, and olfactory hallucinations; and delusions. PDP symptoms typically progress over its course from being mild, infrequent, and often untroubling to complex, sometimes constant, and potentially highly disturbing. PDP has traditionally been treated with atypical antipsychotics (e.g., clozapine and quetiapine) although these are not approved for this indication and clozapine requires frequent white blood cell count monitoring due to the risk of agranulocytosis. Pimavanserin is a newer atypical antipsychotic with highly selective binding to serotonergic receptors, no evidence for worsening motor symptoms in PD, and no need for white blood cell count monitoring. It is currently the only approved medication indicated for PDP treatment. However, because it was approved relatively recently (2016), clinical experience with pimavanserin is limited. Case Presentations. A wide variety of representative clinical scenarios are presented, each with distinct variables and complications. Issues addressed include distinguishing PDP from similar symptoms caused by other disorders such as dementia, coordinating pimavanserin with other PD medications and with deep brain stimulation, adapting pimavanserin dosing for optimal benefit and tolerability, and recognizing variability of PDP symptoms due to patients' changing life circumstances. Conclusions These scenarios provide multiple insights regarding PDP management and the role of pimavanserin. Effective treatment of PDP may reduce disturbing symptoms of psychosis, thus improving patient function and quality of life. In addition, effective pharmacotherapy for PDP may also facilitate the use of other medications needed to treat neurological symptoms of PD (e.g., tremor, bradykinesia, and dyskinesia), although they may also have adverse effects that contribute to symptoms of PDP.
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Bhoopatiraju S, Grossberg G. Emerging Perspectives in the Diagnosis and Management of Depression and Psychosis in Parkinson's Disease. Neurology 2021. [DOI: 10.17925/usn.2021.17.2.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
Introduction: Hallucinations in Parkinson's disease are common, can complicate medication management and significantly impact upon the quality of life of patients and their carers.Areas covered: This review aims to examine current evidence for the management of hallucinations in Parkinson's disease.Expert opinion: Treatment of hallucinations in Parkinson's disease should be both individualized and multifaceted. Screening, education, medication review and the avoidance of common triggers are important. For well-formed visual hallucinations, acetylcholinesterase inhibitors are recommended first-line. Refractory or severe symptoms may require the cautious use of atypical antipsychotics. Antidepressants may be beneficial in the appropriate setting. Unfortunately, current therapies for hallucinations offer only limited benefits and future research efforts are desperately required to improve the management of these challenging symptoms.
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Affiliation(s)
- Alice Powell
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, the University of Sydney, Camperdown, Australia.,Department of Geriatric Medicine, Prince of Wales Hospital, Randwick, Australia
| | - Elie Matar
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, the University of Sydney, Camperdown, Australia
| | - Simon J G Lewis
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, the University of Sydney, Camperdown, Australia
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Hosking A, Hommel AALJ, Lorenzl S, Coelho M, Ferreira JJ, Meissner WG, Odin P, Bloem BR, Dodel R, Schrag A. Characteristics of Patients with Late-Stage Parkinsonism Who are Nursing Home Residents Compared with those Living at Home. J Am Med Dir Assoc 2020; 22:440-445.e2. [PMID: 32723531 DOI: 10.1016/j.jamda.2020.06.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/31/2020] [Accepted: 06/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To determine clinical characteristics and treatment complications of patients with late-stage Parkinsonism living in nursing homes compared with those living at home. DESIGN Cross-sectional analysis. SETTING AND PARTICIPANTS This study is an analysis of 692 patients with late stage Parkinsonism recruited to an in-depth international study, Care of Late-Stage Parkinsonism (CLaSP). MEASURES Sociodemographic characteristics were compared between patients who were living in a nursing home (n = 194) and those living at home (n = 498). Clinical assessments included the Unified Parkinson's Disease Rating Scale (UPDRS), the nonmotor symptom scale, the neuropsychiatric inventory, and a structured interview of patients and carers. Predictors of nursing home status were determined in a multivariate analysis. RESULTS Nursing home placement was strongly associated with more severe cognitive impairment, worse UPDRS motor scores and disability, and with being unmarried and older. Although nursing home residents had significantly higher axial scores, falls were less common. Despite similar levodopa equivalence doses, they had less dyskinesia. Nonmotor symptom burden, particularly delusion, hallucination, and depression scores were higher in nursing home residents, and they were more frequently on psychotropic medication. They had lower rates of dopamine agonist use and lower rates of impulse control disorders. In multivariate analysis, being unmarried, presence of cognitive impairment, worse disease severity as assessed on the UPDRS parts II and III, severity of delusions, and lower rate of dyskinesia were associated with nursing home placement. CONCLUSIONS AND IMPLICATIONS These clinical characteristics suggest that in patients with Parkinsonsim who are nursing home residents, presence of cognitive impairment and delusions particularly add to the higher overall symptom burden, and more often require specific treatments, including clozapine. Despite similar levodopa equivalent daily dose, motor severity is higher, and dyskinesias, indicative of a response to levodopa, are less common. Falls, however, also occur less commonly, and dopamine agonists are less frequently used, with lower rates of impulse control disorder.
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Affiliation(s)
- Alice Hosking
- UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Adrianus A L J Hommel
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behavior, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, the Netherlands; Department of Medicine, University of Otago, Christchurch, New Zealand and New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Stefan Lorenzl
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria; Interdisziplinäres Zentrum für Palliativmedizin und Klinik für Neurologie Universität München, Klinikum Großhadern, Munich, Germany; Department of Neurology, Agatharied Hospital, Hausham, Germany
| | - Miguel Coelho
- Interdisziplinäres Zentrum für Palliativmedizin und Klinik für Neurologie Universität München, Klinikum Großhadern, Munich, Germany
| | - Joaquim J Ferreira
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Wassilios G Meissner
- Department of Medicine, University of Otago, Christchurch, New Zealand and New Zealand Brain Research Institute, Christchurch, New Zealand; Service de Neurologie, CHU de Bordeaux, Université de Bordeaux, Institut des Maladies Neurodégénératives, UMR 5293, Bordeaux, France
| | - Per Odin
- Department of Neurology, Lund University Hospital, Lund, Sweden
| | - Bas R Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behavior, Department of Neurology, Center of Expertise for Parkinson and Movement Disorders, Nijmegen, the Netherlands; Groenhuysen Organisation, Roosendaal, the Netherlands
| | - Richard Dodel
- Department of Geriatric Medicine, University Hospital Essen, Essen, Germany
| | - Anette Schrag
- UCL Queen Square Institute of Neurology, University College London, London, UK.
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Ezzeldin E, Iqbal M, Asiri YA, Ali AA, El-Nahhas T. A rapid, simple and highly sensitive UPLC-MS/MS method for quantitation of pimavanserin in plasma and tissues: Application to pharmacokinetics and brain uptake studies in mice. J Chromatogr B Analyt Technol Biomed Life Sci 2020; 1143:122015. [DOI: 10.1016/j.jchromb.2020.122015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/04/2020] [Accepted: 01/31/2020] [Indexed: 11/17/2022]
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18
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Lee G, Cummings J, Decourt B, Leverenz JB, Sabbagh MN. Clinical drug development for dementia with Lewy bodies: past and present. Expert Opin Investig Drugs 2019; 28:951-965. [PMID: 31614096 PMCID: PMC6823159 DOI: 10.1080/13543784.2019.1681398] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 10/14/2019] [Indexed: 12/25/2022]
Abstract
Introduction: Dementia with Lewy bodies (DLB) is an under-researched area despite being the second most common type of degenerative dementia after Alzheimer's disease. It is an area of unmet need with no approved symptomatic or disease-modifying therapies. The pharmacological management of DLB is complex and challenging because early trials of drugs for DLB have resulted in no demonstrable efficacy. Randomized controlled trials (RCTs) in the DLB population have only recently been initiated. Understanding results from previous and current clinical trials in DLB can provide insights for future research and development.Areas covered: We provide an overview of the DLB drug development landscape and the current treatment strategies. We reviewed ClinicalTrials.gov to identify all clinical trials for the treatment of DLB.Expert opinion: DLB drug development has significantly improved in recent years with eight agents now in clinical trials. However, more rigorous RCTs are urgently needed. Diagnostic criteria must be optimized to accurately diagnose patients for clinical trials and care. New biomarker strategies are necessary to improve diagnostic capabilities and trial designs, and novel drug targets should be identified to develop DLB specific disease-modifying therapies. Evaluating the current drug development landscape can provide insight into how best to optimize development practices.
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Affiliation(s)
- Garam Lee
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - Jeffrey Cummings
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
- Department of Brain Health, School of Integrated Health Science, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Boris Decourt
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
| | - James B Leverenz
- Cleveland Clinic Lou Ruvo Center for Brain Health, Cleveland, OH, USA
| | - Marwan N Sabbagh
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
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19
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Lyons KE, Pahwa R, Hermanowicz N, Davis T, Pagan F, Isaacson S. Changing the treatment paradigm for Parkinson’s disease psychosis with pimavanserin. Expert Rev Clin Pharmacol 2019; 12:681-691. [DOI: 10.1080/17512433.2019.1623669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Kelly E. Lyons
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Rajesh Pahwa
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Neal Hermanowicz
- Department of Neurology, University of California Irvine, Irvine, CA, USA
| | - Thomas Davis
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fernando Pagan
- Department of Neurology, Georgetown University Medical Center, Washington, DC, USA
| | - Stuart Isaacson
- Parkinson’s Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, USA
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Abstract
Dementia with Lewy bodies (DLB) is a complex disease that involves a variety of cognitive, behavioral and neurological symptoms, including progressive memory loss, visual hallucinations, parkinsonism, cognitive fluctuations and rapid eye movement sleep behavior disorder (RBD). These symptoms may appear in varying combinations and levels of severity in each patient who is seen in the clinic, making diagnosis and treatment a challenge. DLB is the third most common of all the neurodegenerative diseases behind both Alzheimer’s disease and Parkinson’s disease (PD). The median age of onset for DLB (76.3 years) is younger than that seen in PD dementia (81.4 years). New pathological studies have shown that most DLB patients have variable amounts of Alzheimer’s changes in their brains, explaining the wide variability in this disease’s clinical presentation and clinical course. This review discusses the three cholinesterase inhibitors that have been shown to be effective in managing the cognitive and behavioral symptoms of DLB: rivastigmine, galantamine and donepezil. Memantine is able to improve clinical global impression of change in those with mild to moderate DLB. Levodopa can treat the parkinsonism of some DLB patients, but the dose is often limited due to the fact that it can cause agitation or worsening of visual hallucinations. A recent phase 2 clinical trial showed the benefit of zonisamide when it is added as an adjunct to levodopa for treating DLB parkinsonism. While atypical antipsychotic drugs may not always be helpful as monotherapy in managing the agitation associated with DLB, low doses of valproic acid can be effective when added as an adjunct to drugs like quetiapine. Pimavanserin may prove to be a useful treatment for psychosis in DLB patients, but like other antipsychotic drugs that are used in dementia patients, there is a small increased risk of mortality. RBD, which is a common core clinical feature of DLB, can be managed with either melatonin or clonazepam. Two agents targeting alpha-synuclein (NPT200-11 and ambroxol) currently hold promise as disease-modifying therapies for DLB, but they are yet to be tested in clinical trials. An agent (E2027) that offers hope of neuroprotection by increasing central cyclic guanosine monophosphate (cGMP) levels is currently being examined in clinical trials in DLB patients.
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Affiliation(s)
- Linda A Hershey
- Department of Neurology, University of Oklahoma Health Sciences Center, 920 Stanton L Young Blvd, Suite 2040, Oklahoma City, OK, 73104-5036, USA.
| | - Rhonda Coleman-Jackson
- Department of Neurology, University of Oklahoma Health Sciences Center, 920 Stanton L Young Blvd, Suite 2040, Oklahoma City, OK, 73104-5036, USA
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Seppi K, Ray Chaudhuri K, Coelho M, Fox SH, Katzenschlager R, Perez Lloret S, Weintraub D, Sampaio C. Update on treatments for nonmotor symptoms of Parkinson's disease-an evidence-based medicine review. Mov Disord 2019; 34:180-198. [PMID: 30653247 PMCID: PMC6916382 DOI: 10.1002/mds.27602] [Citation(s) in RCA: 540] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/26/2018] [Accepted: 12/12/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To update evidence-based medicine recommendations for treating nonmotor symptoms in Parkinson's disease (PD). BACKGROUND The International Parkinson and Movement Disorder Society Evidence-Based Medicine Committee's recommendations for treatments of PD were first published in 2002, updated in 2011, and now updated again through December 31, 2016. METHODS Level I studies testing pharmacological, surgical, or nonpharmacological interventions for the treatment of nonmotor symptoms in PD were reviewed. Criteria for inclusion and quality scoring were as previously reported. The disorders covered were a range of neuropsychiatric symptoms, autonomic dysfunction, disorders of sleep and wakefulness, pain, fatigue, impaired olfaction, and ophthalmologic dysfunction. Clinical efficacy, implications for clinical practice, and safety conclusions are reported. RESULTS A total of 37 new studies qualified for review. There were no randomized controlled trials that met inclusion criteria for the treatment of anxiety disorders, rapid eye movement sleep behavior disorder, excessive sweating, impaired olfaction, or ophthalmologic dysfunction. We identified clinically useful or possibly useful interventions for the treatment of depression, apathy, impulse control and related disorders, dementia, psychosis, insomnia, daytime sleepiness, drooling, orthostatic hypotension, gastrointestinal dysfunction, urinary dysfunction, erectile dysfunction, fatigue, and pain. There were no clinically useful interventions identified to treat non-dementia-level cognitive impairment. CONCLUSIONS The evidence base for treating a range of nonmotor symptoms in PD has grown substantially in recent years. However, treatment options overall remain limited given the high prevalence and adverse impact of these disorders, so the development and testing of new treatments for nonmotor symptoms in PD remains a top priority. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Klaus Seppi
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - K Ray Chaudhuri
- Institute of Psychiatry, Psychology & Neuroscience at King's College and Parkinson Foundation International Centre of Excellence at King's College Hospital, Denmark Hill, London, United Kingdom
| | - Miguel Coelho
- Serviço de Neurologia, Hospital Santa Maria Instituto de Medicina Molecular Faculdade de Medicina de Lisboa, Lisboa, Portugal
| | - Susan H Fox
- Edmond J Safra Program in Parkinson Disease, Movement Disorder Clinic, Toronto Western Hospital, and the University of Toronto Department of Medicine, Toronto, Ontario, Canada
| | - Regina Katzenschlager
- Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Danube Hospital, Vienna, Austria
| | - Santiago Perez Lloret
- Institute of Cardiology Research, University of Buenos Aires, National Research Council, Buenos Aires, Argentina
| | - Daniel Weintraub
- Departments of Psychiatry and Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Parkinson's Disease and Mental Illness Research, Education and Clinical Centers, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Cristina Sampaio
- CHDI Management/CHDI Foundation, Princeton, NJ, USA
- Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
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Koduri GB, Bollikolla HB, Dittakavi R, Navuluri S. Quantification of Pimavanserin in Bulk and Tablet Dosage Form Using A Stability Indicating High Performance Liquid Chromatographic Method. PHARMACEUTICAL SCIENCES 2018. [DOI: 10.15171/ps.2018.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Pimavanserin, an antipsychotic agent, is used to treat patients suffering with Parkinson's disease. Till now no stability indicating reverse phase HPLC method was reported for the quantification of pimavanserin in bulk and tablet dosage form. Hence in the present study, a new sensitive, precise and accurate stability indicating reverse phase HPLC method with photodiode array detector has been developed for the quantification of pimavanserin in bulk and tablet dosage form. Methods: Separation and analysis of pimavanserin was achieved on Kromasil C18 (5 µm, 250 mm × 4.6 mm) column using 0.1M NaH2PO4, methanol and acetonitrile in ratio of 55:30:15 (v/v/v) as mobile phase at 25°C. The flow rate was 1.0 ml/min. The effluents were monitored with detector set at 239 nm. The method validation was done with regard to the guidelines by the International Conference on Harmonization. Pimavanserin was subjected to acid, alkali and neutral hydrolysis, hydrogen peroxide oxidation, thermal degradation, and photo (sunlight) degradation. Results: Linear relationship was obtained between the concentration of drug and peak area response in the range of 4.25-34.0 µg/ml. The limits of detection and quantitation were found to be 0.027 µg/ml and 0.089 µg/ml, respectively. All the validation characteristics were within the acceptance criteria. The peaks of degradation products were well resolved from the pimavanserin peak. Conclusion: The developed and validated method is able to quantify the pimavanserin in the presence of degradation products.
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Affiliation(s)
- Geetha Bhavani Koduri
- JMJ College for Womens, Tenali, Andhra Pradesh, India
- Department of Science and Humanities, Vignan University, Vadlamudi, A.P., India
| | - Hari Babu Bollikolla
- Department of Chemistry, Acharya Nagarjuna University, Nagarjuna Nagar, Guntur. A.P., India
| | - Ramachandran Dittakavi
- Department of Chemistry, Acharya Nagarjuna University, Nagarjuna Nagar, Guntur. A.P., India
| | - Srinivasu Navuluri
- Department of Science and Humanities, Vignan University, Vadlamudi, A.P., India
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Guidance for switching from off-label antipsychotics to pimavanserin for Parkinson's disease psychosis: an expert consensus. CNS Spectr 2018; 23:402-413. [PMID: 30588905 DOI: 10.1017/s1092852918001359] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Patients with Parkinson's disease psychosis (PDP) are often treated with an atypical antipsychotic, especially quetiapine or clozapine, but side effects, lack of sufficient efficacy, or both may motivate a switch to pimavanserin, the first medication approved for management of PDP. How best to implement a switch to pimavanserin has not been clear, as there are no controlled trials or case series in the literature to provide guidance. An abrupt switch may interrupt partially effective treatment or potentially trigger rebound effects from antipsychotic withdrawal, whereas cross-taper involves potential drug interactions. A panel of experts drew from published data, their experience treating PDP, lessons from switching antipsychotic drugs in other populations, and the pharmacology of the relevant drugs, to establish consensus recommendations. The panel concluded that patients with PDP can be safely and effectively switched from atypical antipsychotics used off label in PDP to the recently approved pimavanserin by considering each agent's pharmacokinetics and pharmacodynamics, receptor interactions, and the clinical reason for switching (efficacy or adverse events). Final recommendations are that such a switch should aim to maintain adequate 5-HT2A antagonism during the switch, thus providing a stable transition so that efficacy is maintained. Specifically, the consensus recommendation is to add pimavanserin at the full recommended daily dose (34 mg) for 2-6 weeks in most patients before beginning to taper and discontinue quetiapine or clozapine over several days to weeks. Further details are provided for this recommendation, as well as for special clinical circumstances where switching may need to proceed more rapidly.
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Berman BD, Hawkins T. Author response: Pimavanserin: A novel therapeutic option for Parkinson disease psychosis. Neurol Clin Pract 2018; 8:175-176. [DOI: 10.1212/cpj.0000000000000470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Keys Lawler AC, Torres-Yaghi Y, Amjad F, Moussa C, Pagan F. Reader response: Pimavanserin: A novel therapeutic option for Parkinson disease psychosis. Neurol Clin Pract 2018; 8:175. [DOI: 10.1212/cpj.0000000000000467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kataoka H, Sugie K. Delusional Jealousy (Othello Syndrome) in 67 Patients with Parkinson's Disease. Front Neurol 2018; 9:129. [PMID: 29563893 PMCID: PMC5845894 DOI: 10.3389/fneur.2018.00129] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 02/21/2018] [Indexed: 11/18/2022] Open
Abstract
Othello syndrome (OS) is a type of paranoid delusional jealousy, characterized by the false absolute certainty of the infidelity of a partner. Because OS has infrequently occurred in patients with Parkinson’s disease (PD), the characteristics of OS in PD remain unclear. We reviewed the clinical characteristics of this syndrome in PD. We reviewed 67 patients who had PD with OS. OS was more common in men (45 patients) than in women (22 patients), and it frequently occurred in middle-aged patients. Until the onset of OS, the duration of PD (range, 2–19.8 years) and the duration of treatment with PD medications (range, 2 months to 18.5 years) varied. At the onset of OS, cognition was preserved in most patients. 42 of 47 patients had other psychiatric disorders in addition to OS, and 5 patients had isolated OS. Persecutory or other paranoid delusions developed in 34 patients with OS. OS was associated with PD medication in 25 of 26 patients, especially in patients, used the dopamine agonists. The dose of the PD medication associated with OS was decreased or these drugs were withdrawn to facilitate the treatment of OS. In most patients, OS disappeared or the severity of OS was reduced. OS is infrequent in patients with PD, but is likely to be easily detected because OS is commonly accompanied by persistent paranoid and sexual delusions. When clinicians encounter such patients, the withdrawal or reduction of dopamine agonists should be attempted, and if necessary, additional treatment with clozapine is recommended.
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Affiliation(s)
- Hiroshi Kataoka
- Department of Neurology, Nara Medical University, Kashihara, Japan
| | - Kazuma Sugie
- Department of Neurology, Nara Medical University, Kashihara, Japan
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Optimizing Care for Older Adults With Dementia-Associated Psychosis. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2017.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Pimavanserin: A novel therapeutic option for Parkinson disease psychosis. Neurol Clin Pract 2017; 7:282. [DOI: 10.1212/cpj.0000000000000380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Pringsheim T. Neurology and mental health. Neurol Clin Pract 2017; 7:96-97. [DOI: 10.1212/cpj.0000000000000345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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