Role of zonisamide in advanced Parkinson's disease: a randomized placebo-controlled study

BACKGROUND

Zonisamide (ZNS) has shown some efficacy in motor symptoms of PD; however, more evidence is lacking, and its effects on nonmotor symptoms (NMSs) and quality of life (QoL) remain to be investigated. This randomized double-blinded placebo-controlled crossover study investigated the effect of ZNS on motor and NMS symptoms and QoL in advanced PD.

METHODS

PD patients with Hoehn and Yahr stage ≥ 2 ("On" state) and at least 2 h off time daily were randomized to groups: ZNS 25 mg, ZNS 50 mg and placebo. Groups were assessed at baseline and at the 1- and 3-month follow-ups. The primary endpoint was the change in the total MDS-UPDRS III "On", while the secondary endpoint was the change in the total and parts I and IV MDS-UPDRS, Nonmotor Symptoms Scale and Parkinson's disease questionnaire-39 at the final assessment.

RESULTS

Sixty-nine patients were assessed for efficacy at the 1-month follow-up, and 58 patients were assessed at the 3-month follow-up. The primary endpoint showed significant improvement in the ZNS 25 mg group compared to the placebo group (p = 0.009). At the final assessment, the ZNS 25 mg group showed significant improvement of total and part VI MDS-UPDRS, bradykinesia, tremor and functional impact of fluctuations compared to placebo. There was no change in dyskinesia, NMSs, QoL or side effects except for sedation.

CONCLUSION

ZNS has a favourable effect on motor symptoms in patients with wearing off as adjunctive therapy with other dopaminergic drugs, with no exacerbation of dyskinesia and a limited impact on NMSs and QoL.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04182399, in 24/11/2019.

Intrinsic auricular muscle zone stimulation for Parkinson disease: The EARSTIM-PD Phase II multi-center pilot study results

BACKGROUND

Studies have suggested that intrinsic auricular muscle zones (IAMZ) stimulation alleviates motor features of Parkinson disease (PD).

METHODS

A randomized, blinded, active sham-controlled pilot trial was conducted to evaluate the safety and dose-response-time curve of Earstim using a 3-treatment, 3-period crossover design in PD patients experiencing OFF time on levodopa. Treatments were: short (20-min) IAMZ stimulation; long (60-min) IAMZ stimulation; and 20-min active sham stimulation of non-muscular areas. Assessment time points were: prior to treatment, and 20, 40, 60, 90, and 120 min after treatment onset. Primary safety endpoints were adverse events frequency and severity. Primary efficacy endpoint was the change in MDS-UPDRS motor score at 20 min after treatment onset in the IAMZ treatment groups versus sham.

RESULTS

Forty-six individuals consented; 38 were randomized (average age 64 years, 65 % male, mean 8.2 years from diagnosis). No serious adverse events or significant device-related events occurred. At 20 min after treatment onset, motor improvements did not differ between IAMZ treatments versus sham. However, at 60 min after treatment onset, motor improvement peaked on IAMZ treatments compared to sham (difference: 3.1 [-5.9 to 0.3], p = 0.03). While the difference in 120-min AUC change between IAMZ treatments versus sham was not significant, the short-stimulation IAMZ treatment showed the largest aggregate motor score improvement (AUC = -456 points, 95 % CI -691 to -221) compared to sham.

CONCLUSION

Earstim was well-tolerated. The greatest motor improvement occurred at 60 min after stimulation onset in the short-stimulation IAMZ treatment, and supports its further study to alleviate OFF periods.

Zonisamide improves wearing off in Parkinson's disease without exacerbating dyskinesia: Post hoc analysis of phase 2 and phase 3 clinical trials

INTRODUCTION

Although phase 2 and 3 clinical trials in Japan showed that zonisamide improved wearing off in patients with Parkinson's disease (PD), no studies to date have evaluated whether zonisamide improves wearing off in patients with PD without exacerbating dyskinesia. Therefore, we examined this hypothesis in a post hoc analysis of pooled data from the previous phase 2 and 3 trials.

METHODS

Both trials evaluated zonisamide 25 mg and 50 mg versus placebo during a 12-week treatment period. In our analysis, primary efficacy variables were adjusted mean change in wearing off (evaluated as change in "off" time) and dyskinesia from baseline to 12 weeks. Dyskinesia was evaluated using Unified Parkinson's Disease Rating Scale (UPDRS) part 4 items 32 (4-32; duration of dyskinesia) and 33 (4-33; disability of dyskinesia) score. Criteria outcomes included rates of patients meeting specific criteria based on off time plus UPDRS part 4-32 or 4-33.

RESULTS

A total of 212 patients were included in this analysis. Zonisamide 50 mg significantly reduced off time and UPDRS part 4-33 score at week 12 versus placebo without increasing UPDRS part 4-32 score. The proportion of patients receiving zonisamide 50 mg who met the criterion "Off time decreased and UPDRS part 4-33 score did not increase" was significantly higher than that of patients receiving placebo.

CONCLUSION

Zonisamide improves wearing off without exacerbating dyskinesia in Japanese patients with PD. Moreover, zonisamide 50 mg may improve dyskinesia. Further studies are needed to prospectively determine the benefits and clinical relevance of zonisamide on dyskinesia.

Assessment of Wearing Off in Parkinson's disease using objective measurement

BACKGROUND

Development of "Wearing Off" (WO) of motor and non-motor function in Parkinson's disease (PD) adversely affects quality of life. This suggest that identifying and treating WO is important. However, identification of WO depends on people with PD (PwP) recognising and reporting WO and there is a perception that WO may be significantly underestimated.

OBJECTIVE

We investigate the feasibility of identifying "Wearing Off" using objective measurement and assess the clinical benefit in rectifying it.

METHOD

In this study, 200 PwP were studied for evidence of WO using a continuously worn wearable system. Eighty-five patients (43%) were found to have WO and treatment was changed to mitigate the effects of WO.

RESULTS

Factors, such as duration of disease, high baseline MDS-UPDRS (motor component), high Percent Time in Bradykinesia (PTB), high Levodopa Equivalent Daily Dose (LEDD), frequent Levodopa doses and younger age of onset, are associated with severity of motor complications. Patients with more severe WO experienced worse motor and non-motor symptoms and lower quality of life. Quality of life significantly improved in PwP when WO was treated.

CONCLUSION

The findings reported in this study provide evidence that identifying and treating WO improves outcomes of PwP and that objective measurements may help clinicians to identify and treat WO.

Validating the Vietnamese version of wearing - Off 19 questionnaire for patients with Parkinson's disease

BACKGROUND

One of the most common complication of the progression of Parkinson's disease (PD) is the wearing off phenomenon. A validated Vietnamese version of Wearing off 19 (WO19) questionnaire is necessary to optimize the Vietnamese PD treatment.

OBJECTIVES

This study was undertaken to determine the quality attribute of the questionnaire as a tool for early detection of wearing off (WO) in Vietnamese population with PD. We also sought the relationship between the WO phenomenon and factors concerning the clinical condition and course of the disease.

SUBJECTS AND METHODS

This is an observational, cross-sectional study. Patients diagnosed with PD under dopaminergic treatment came to University Medical Center Ho Chi Minh city for a regular appointment were sequentially asked to complete the Vietnamese WO19 questionnaire. A neurologist specialized in movement disorders assessed the patient and determined whether he had experienced wearing off or not. The questionnaire results were then compared to the clinical opinion of the expert which is considered the gold standard for diagnosing wearing off. The reliability of the questionnaire is evaluated by Cronbach'α and Cohen's kappa coefficient. The validity is measured by the sensitivity and the specificity of the instrument compared to the gold standard. The multivariate logistic regression analysis is used to learn the relations of associated factors and wearing off phenomenon.

RESULTS

98 patients with the mean age 59.12 ± 10.99 have joined our study; 58.2% are male; and the mean disease duration is 6.32 years. The Vietnamese version of the WO19 questionnaire has a good reliability (Cronbach'α = 0.778) and the agreement with the expert assessment (the diagnostic accuracy) is at a substantial level (Kappa value = 0.618). The sensitivity and specificity of the questionnaire resulted 89.28% and 71.43% respectively. The multivariate logistic regression analysis revealed a long disease duration (≥6 years) (OR: 16.96; 95% CI: 2.17-132.57; p = 0.007), a high daily levodopa dosage (≥400 mg/day) (OR: 6.31; 95% CI: 1.36-29.23; p = 0.019) and high score of MDS-UPDRS part IV (≥4) (OR: 15.36; 95% CI: 2.13-110.58; p = 0.007) were independent predictive factors for wearing off in Vietnamese PD patients.

CONCLUSIONS

Vietnamese - WO19 is a reliable and effective tool which should be used in clinical practice for early detecting PD patients with wearing off.

The spectrum of "off" in Parkinson's disease: What have we learned over 40 years?

The terms "on" and "off" were used by Marsden and his contemporaries over 40 years ago to describe times when Parkinson's disease patients experienced good motor function ("on") and immobility ("off"). Yet there remains no published consensus definition of "off", leading clinicians and patients to develop individualized impressions of "off" determinations. In this paper, we first discuss the evolution of the terminology and understanding of "off" states since Marsden's time, which now include non-motor as well as motor symptoms. We then review pathophysiology and risk factors for the development of "off" states as well as tools to detect the "off" state, before proposing a practical definition of "off" for consideration. A common, practical definition of the "off" state could improve clinical recognition of "off" symptoms and lead to significant benefit for patients.

Long-term treatment of Parkinson's disease with levodopa and other adjunctive drugs

We report a long-term treatment of Parkinson’s disease in out-patient clinics. The patients with Parkinson’s disease were evaluated at the time of clinic visit from September 1st, 2015 to February 29th, 2016. Total number of the patients was 498. The age at the evaluation was 69.9 ± 9.3 years and the age of onset was 60.2 ± 11.3. Hoehn and Yahr severity was 3.28 ± 0.94 in patients who were from 16 to 20 years (n = 53) and 3.00 ± 0.86 in patients from 21 years or more (n = 38) from the onset of the disease to the evaluation. The dose of levodopa was 741 ± 295 mg per day and the number of levodopa dosing was 5.85 ± 2.59 times in 16–20 years from the onset to the evaluation and 703 ± 251 mg/day and 6.03 ± 3.20 times a day in 21 years or more from the onset to the evaluation. Levodopa was given in most cases into an empty stomach. The incidence of wearing off was 73.6% and dyskinesia was 37.7% in the 16–20 years group and 76.3% and 55.3% in 21 years or more group, respectively. The patients who had 15 years or less from the onset to the evaluation had much milder severity of the disease. Hoehn and Yahr severity, the dose of levodopa, and the incidence of wearing off were about the same as in the literature. But the incidence of dyskinesia was much lower than those appeared in the literature. We discussed reasons why the incidence of dyskinesia was lower in our study.

Gender and non motor fluctuations in Parkinson's disease: A prospective study

INTRODUCTION

In Parkinson's disease (PD), non motor symptoms can fluctuate either along or irrespective to motor on/off phenomena. Prospective studies suggest that higher motor scores and levodopa dosage, younger age at onset and female gender represent risk factors for motor fluctuations' development. Yet, the predictors of development of non motor fluctuations (NMF) are less clear. In this prospective study, we aimed to assess the relationship between NMF and gender along with other potential risk factors.

METHODS

Forty-seven (16 women/31 men) de novo, drug-naïve PD patients have been followed for 4 years since diagnosis. Motor and non motor fluctuations were evaluated with the 19-item Wearing off Questionnaire (WOQ-19). The association between gender and NMF was explored with multivariable regression models adjusted for age at onset, motor and non motor symptoms at diagnosis and levodopa intake at follow up.

RESULTS

Female gender was more likely associated with a diagnosis of NMF (adjusted odds ratio, AOR = 5.33,95%CI = 1.21-23.4, p = 0.027), but not with a diagnosis of generic wearing off at follow up (OR = 3.66, 95%CI = 0.8-16.8, p = 0.097). Women had greater likelihood of developing higher WOQ-19 Non motor scores (AOR = 4.58, 95%CI = 1.23-17.03, p = 0.023), but not higher WOQ-19 Total scores (AOR = 2.88, 95%CI = 0.86-9.71, p = 0.087) compared to men. Notwithstanding, no gender differences were detected in medication intake.

CONCLUSIONS

We showed that female gender represents a major risk factor for the development of NMF. There were no gender differences in medication intake, thus NMF in women remain mostly underestimated and not properly treated. From a practical standpoint, clinicians should take into account the role of gender in the management of NMF in PD.

Normal substantia nigra patients treated with levodopa - Clinical, therapeutic and pathological observations

BACKGROUND

Definite diagnosis of idiopathic Parkinson's disease is based on histological findings of marked substantia nigra neuronal loss and Lewy body inclusions. Almost all cases with clinical diagnosis of idiopathic Parkinson's disease are treated with levodopa. Because there is no biological marker for the diagnosis, erroneous clinical diagnosis and treatment of such cases with levodopa are well known. There is very limited literature on levodopa treated cases that had normal substantia nigra at autopsy.

METHODS

Patients seen at Movement Disorders Clinic Saskatchewan are offered autopsy at no cost to the family/estate of the patient. Autopsy studies are performed by certified neuropathologists. Notation on the status of substantia nigra is made in every autopsied case.

RESULTS

Between 1968 and 2014, 21 cases treated with levodopa had normal substantia nigra at autopsy. Eleven patients continued levodopa until death and 9 received the drug for four years or longer. No objective motor symptom benefit, dyskinesia or motor response fluctuations on levodopa were observed in any case. The most common final diagnosis was essential tremor.

CONCLUSION

Individuals with normal substantia nigra do not benefit from levodopa and do not manifest motor response fluctuations or dyskinesia. Long-term use of levodopa is not toxic to normal human substantia nigra.