Long-term, open-label, phase 3 study of rasagiline in Japanese patients with early Parkinson's disease

Effects of MAO‑B inhibitors in life quality of Parkinson's disease patients: A systematic review and meta‑analysis

INTRODUCTION

Monoamine oxidase-B (MAO-B) inhibitors, as an add-on therapy to levodopa, are widely used in Parkinson's disease (PD). The effects of MAO-B inhibitors on quality of life remain unclear, and the aim of this systematic review and meta-analysis was to assess the efficacy and safety of MAO-B inhibitors on quality of life in different domains.

METHODS

We searched PubMed, Embass, and Cochrane Library databases for randomized controlled trials of PD patients who were administered MAO-B inhibitors. Outcomes were the change from baseline in the total score of life quality scales, change from baseline in domains of the Parkinson's Disease Questionnaire-39 (PDQ-39), and incidence of treatment-associated adverse events (TAEs).

RESULTS

Sixteen studies covering 4734 PD patients were included in the study. The PDQ-39 scores were lower with MAO-B inhibitors than with placebo (SMD: -0.26, 95 % CI: [-0.49, -0.04], P = 0.02). The European Quality of Life Questionnaire-5D (EQ-5D) scores were higher in the MAO-B inhibitor group. Patients treated with MAO-B inhibitors had better performance in the domains of mobility, activities of daily living, emotional well-being, stigma, communication, and bodily discomfort, except for social support and cognition. The incidence of TAEs was slightly higher in patients treated with MAO-B inhibitors.

CONCLUSIONS

Evidence has shown that MAO-B inhibitors, especially safinamide, are effective in improving the quality of life of PD patients, although with a slightly higher incidence of TAEs. The domains of quality of life were improved, except for cognition and social support, compared with placebo. Further studies are warranted to evaluate the effects of other MAO-B inhibitors on quality of life.

Comprehensive data for studying serum exosome microRNA transcriptome in Parkinson's disease patients

Parkinson's disease (PD), the second most prevalent neurodegenerative disorder, was classically attributed to alpha-synuclein aggregation and consequent loss of dopaminergic neurons in the substantia nigra pars compacta. Recently, emerging evidence suggested a broader spectrum of contributing factors, including exosome-mediated intercellular communication, which can potentially serve as biomarkers and therapeutic targets. However, there is a remarkable lack of comprehensive studies that connect the serum exosome microRNA (miRNA) transcriptome with demographic, clinical, and neuroimaging data in PD patients. Here, we present serum exosome miRNA transcriptome data generated from four cohort studies. Two of these studies include 96 PD patients and 80 age- and gender-matched controls, with anonymised demographic, clinical, and neuroimaging data provided for PD patients. The other two studies involve 96 PD patients who were evaluated both before and after one year of treatment with rasagiline, a widely prescribed anti-parkinsonism drug. Together, the datasets provide a valuable source for understanding pathogenesis and discovering biomarkers and therapeutic targets in PD.

Monoamine oxidase and neurodegeneration: Mechanisms, inhibitors and natural compounds for therapeutic intervention

Mammalian flavoenzyme Monoamine oxidase (MAO) resides on the outer mitochondrial membrane (OMM) and it is involved in the metabolism of different monoamine neurotransmitters in brain. During MAO mediated oxidative deamination of relevant substrates, H2O2 is released as a catalytic by-product, thus serving as a major source of reactive oxygen species (ROS). Under normal conditions, MAO mediated ROS is reported to propel the functioning of mitochondrial electron transport chain and phasic dopamine release. However, due to its localization onto mitochondria, sudden elevation in its enzymatic activity could directly impact the form and function of the organelle. For instance, in the case of Parkinson's disease (PD) patients who are on l-dopa therapy, the enzyme could be a concurrent source of extensive ROS production in the presence of uncontrolled substrate (dopamine) availability, thus further impacting the health of surviving neurons. It is worth mentioning that the expression of the enzyme in different brain compartments increases with age. Moreover, the involvement of MAO in the progression of neurological disorders such as PD, Alzheimer's disease and depression has been extensively studied in recent times. Although the usage of available synthetic MAO inhibitors has been instrumental in managing these conditions, the associated complications have raised significant concerns lately. Natural products have served as a major source of lead molecules in modern-day drug discovery; however, there is still no FDA-approved MAO inhibitor which is derived from natural sources. In this review, we have provided a comprehensive overview of MAO and how the enzyme system is involved in the pathogenesis of different age-associated neuropathologic conditions. We further discussed the applications and drawbacks of the long-term usage of presently available synthetic MAO inhibitors. Additionally, we have highlighted the prospect and worth of natural product derived molecules in addressing MAO associated complications.

Safety and effectiveness of rasagiline in patients with Parkinson's disease in Japan: a post-marketing surveillance study

BACKGROUND

Rasagiline is a monoamine oxidase B inhibitor for the treatment of Parkinson's disease (PD). This study assessed the safety and effectiveness of rasagiline in patients with PD in routine clinical practice in Japan.

RESEARCH DESIGN AND METHODS

This multicenter, prospective, observational study (148 sites) enrolled patients (1 November 2018-31 October 2020) with PD. Patients received rasagiline orally 1 mg once daily; maximum observation period was 24 months. The incidence of adverse drug reactions (ADRs) was evaluated; effectiveness was assessed using the Unified Parkinson's Disease Rating Scale (UPDRS) Part III total score.

RESULTS

The safety analysis set comprised 961 patients (mean age, 72.50 years; 53.80% female; mean duration of PD, 6.82 years). Mean treatment duration was 14.74 months, with 42.25% receiving rasagiline for ≥ 19 months; 189 (19.67%) had ≥ 1 ADR. Common ADRs were dyskinesia (4.06%), orthostatic hypotension (2.29%), hallucination (1.87%), visual hallucination, nausea, fall (1.56% each), dizziness (1.35%), and somnolence (1.25%). Mean (standard deviation) UPDRS Part III total score was 28.5 (14.35) at baseline and 25.5 (14.98) at the final assessment.

CONCLUSIONS

No new concerns in safety and effectiveness regarding rasagiline in Japanese patients with PD were raised.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03727139; Japan Pharmaceutical Information Center Clinical Trials Information: JapicCTI-184181.

Using Movement Disorder Society Unified Parkinson's Disease Rating Scale Parts 2 and 3 Simultaneously: Combining the Patient Voice with Clinician Ratings

BACKGROUND

Regulatory recommendations favor outcomes combining objective and patient input. The Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS), the most commonly used scale in Parkinson's disease (PD), includes patient and investigator ratings in distinct parts, but original clinimetric analyses failed to confirm the validity of combining parts by simple summing.

OBJECTIVES

The aim was to develop clinimetrically valid constructs for combining patient-reported Part 2 and investigator-rated Part 3 MDS-UPDRS scores.

METHODS

Using 7888 MDS-UPDRS scores, we assessed construct validity of combined Part 2 and Part 3 items using exploratory factor analysis (EFA) and graded item response theory (IRT) with threshold criteria: comparative fit index ≥0.9 (EFA) and discrimination parameters ≥0.65 (IRT).

RESULTS

The direct sum of Parts 2 + 3 failed to meet the threshold for a valid outcome of PD severity (comparative fit index, CFI = 0.855). However, a two-domain construct combining item scores for tremor and non-tremor domains from Parts 2 and 3 confirmed validity, meeting both EFA and IRT criteria as distinct but correlated indices of disease severity (CFI = 0.923; discrimination mean 2.197 ± 0.480 [tremor] and 1.737 ± 0.344 [non-tremor] domains).

CONCLUSIONS

The sum of Parts 2 + 3 is not clinimetrically sound. However, considering tremor and non-tremor items of both Parts 2 and 3 as two outcomes results in a valid summary of PD motor severity that leverages simultaneous patient- and investigator-derived measures. This analytic application addresses regulatory prioritizations and retains the well-validated MDS-UPDRS items. In future interventional trials, we suggest that tremor and non-tremor components of PD motor severity from Parts 2 + 3 be monitored and analyzed to accurately detect objective changes that integrate the patient's voice. © 2023 International Parkinson and Movement Disorder Society.

It Is as It Was: MDS-UPDRS Part III Scores Cannot Be Combined with Other Parts to Give a Valid Sum

BACKGROUND

Original clinimetric analyses by the Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) developers did not confirm the validity of summing the scores of its parts. Recent studies used the summed score of Part III and other parts as efficacy outcomes.

OBJECTIVE

The aim of this study was to establish whether summing scores of MDS-UPDRS parts can be recommended.

METHODS

Using 7466 full MDS-UPDRS scores, we applied two-step factor analysis as in the original article to reassess the validity analysis with the threshold criterion set at comparative fit index ≥0.9.

RESULTS

All comparative fit indexes of any combination including Part III were lower than 0.90.

CONCLUSIONS

Summing Part III MDS-UPDRS scores with other parts is not clinimetrically sound. The MDS-UPDRS is a validated four-part scale with corresponding individual part scores and needs to be used within the limits originally presented. © 2022 International Parkinson and Movement Disorder Society.

Rasagiline as Adjunct to Levodopa for Treatment of Parkinson’s Disease: A Systematic Review and Meta-Analysis

Background

Rasagiline is a selective, irreversible monoamine oxidase type B inhibitor used as monotherapy in early Parkinson's disease and as an adjunct therapy to levodopa in Parkinson's disease with motor fluctuations.

Objectives

This meta-analysis aimed to provide updated evidence on the efficacy for motor and nonmotor symptoms and the safety of rasagiline/levodopa versus levodopa in patients with Parkinson's disease experiencing motor fluctuations.

Methods

A systematic literature search was conducted (January 18-19, 2021) using PubMed, Cochrane Library, EMBASE, Web of Science, and Google Scholar to identify randomized controlled trials comparing rasagiline/levodopa versus placebo/levodopa in patients with Parkinson's disease experiencing motor fluctuations. Outcomes included change in wearing-off time, Unified Parkinson's Disease Rating Scale (UPDRS)/Movement Disorder Society-UPDRS (MDS-UPDRS) II and III scores, treatment-emergent adverse events (TEAEs), and Parkinson's Disease Questionnaire (PDQ-39) summary index score. A random effect model was used to estimate the treatment effects.

Results

Six studies were included (1912 patients). Significant improvements in wearing-off time (standardized mean difference [SMD]: −0.50, 95% confidence interval [CI]: –0.92 to –0.09, p = 0.002), levodopa dosage (SMD: −0.18, 95% CI: −0.35 to –0.01, p = 0.041), UPDRS/MDS-UPDRS II (SMD: −0.39, 95% CI: −0.52 to –0.25, p < 0.0001), UPDRS/MDS-UPDRS III (SMD: −0.30, 95% CI: −0.44 to –0.16, p < 0.0001), and PDQ-39 summary index score (SMD: –0.21, 95% CI: –0.37 to –0.04, p = 0.013) were observed with rasagiline/levodopa versus placebo/levodopa. The incidence of TEAEs did not differ between treatments (risk ratio: 1.13, 95% CI: 0.98–1.30, p = 0.093).

Conclusions

This meta-analysis further indicated the superiority of rasagiline/levodopa in improving motor and nonmotor symptoms of Parkinson's disease, with a similar safety profile to that of levodopa in Parkinson's disease with motor fluctuations.

Effects of MAO-B inhibitors on non-motor symptoms and quality of life in Parkinson's disease: A systematic review

Non-motor symptoms (NMS) are common among patients with Parkinson's disease and reduce patients' quality of life (QOL). However, there remain considerable unmet needs for NMS management. Three monoamine oxidase B inhibitors (MAO-BIs), selegiline, rasagiline, and safinamide, have become commercially available in many countries. Although an increasing number of studies have reported potential beneficial effects of MAO-BIs on QOL and NMS, there has been no consensus. Thus, the primary objective of this study was to provide an up-to-date systematic review of the QOL and NMS outcomes from the available clinical studies of MAO-BIs. We conducted a literature search using the PubMed, Scopus, and Cochrane Library databases in November 2021. We identified 60 publications relevant to this topic. Overall, rasagiline and safinamide had more published evidence on QOL and NMS changes compared with selegiline. This was likely impacted by selegiline being introduced many years prior to the field embarking on the study of NMS. The impact of MAO-BIs on QOL was inconsistent across studies, and this was unlikely to be clinically meaningful. MAO-BIs may potentially improve depression, sleep disturbances, and pain. In contrast, cognitive and olfactory dysfunctions are likely unresponsive to MAO-BIs. Given the paucity of evidence and controlled, long-term studies, the effects of MAO-BIs on fatigue, autonomic dysfunctions, apathy, and ICD remain unclear. The effects of MAO-BIs on static and fluctuating NMS have never been investigated systematically. More high-quality studies will be needed and should enable clinicians to provide personalized medicine based on a non-motor symptom profile.

Monoamine Oxidase-B Inhibitors for the Treatment of Parkinson's Disease: Past, Present, and Future

Monoamine oxidase-B (MAO-B) inhibitors are commonly used for the symptomatic treatment of Parkinson's disease (PD). MAO-B inhibitor monotherapy has been shown to be effective and safe for the treatment of early-stage PD, while MAO-B inhibitors as adjuvant drugs have been widely applied for the treatment of the advanced stages of the illness. MAO-B inhibitors can effectively improve patients' motor and non-motor symptoms, reduce "OFF" time, and may potentially prevent/delay disease progression. In this review, we discuss the effects of MAO-B inhibitors on motor and non-motor symptoms in PD patients, their mechanism of action, and the future development of MAO-B inhibitor therapy.

[Pharmacological properties and clinical efficacy of rasagiline mesylate (Azilect®)]

Parkinson's disease is a neurodegenerative disorder that manifests as motor deficits, tremors, rigidity, and postural instability. The most prominent pathological feature of this disease is reduced striatal dopamine concentration due to the loss of nigrodopaminergic neurons. Symptomatic dopamine replacement therapy is the standard management approach for Parkinson's disease. Treatment with monoamine oxidase B (MAO-B) inhibitors also improves Parkinson's disease symptoms by inhibiting the striatal dopamine metabolism and increasing the intracerebral dopamine concentration. Rasagiline is a potent and specific MAO-B inhibitor and is currently approved as an antiparkinsonian drug in more than 50 countries, including the United States and European countries. Clinical trials conducted in Japan to evaluate the efficacy of rasagiline monotherapy in patients with early-stage Parkinson's disease using the Movement Disorder Society-Unified Parkinson's Disease Rating Scale Part II (patient motor experience of daily living) and Part III (clinician motor examination) have demonstrated the antiparkinsonian action of rasagiline. Furthermore, in patients with advanced Parkinson's disease receiving levodopa, concomitant rasagiline administration reduced the duration of "wearing-off". Based on these favorable results, rasagiline mesilate (Azilect^® tablets) was approved for manufacture and sales in Japan in March 2018. Here, we provide a comprehensive overview of the pharmacological properties and clinical effects of rasagiline based on the results of domestic trials, with the aim of increasing the understanding of rasagiline use in Japan.