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Chaudhuri KR, Azulay JP, Odin P, Lindvall S, Domingos J, Alobaidi A, Kandukuri PL, Chaudhari VS, Parra JC, Yamazaki T, Oddsdottir J, Wright J, Martinez-Martin P. Economic Burden of Parkinson's Disease: A Multinational, Real-World, Cost-of-Illness Study. Drugs Real World Outcomes 2024; 11:1-11. [PMID: 38193999 DOI: 10.1007/s40801-023-00410-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Parkinson's disease is now one of the fastest-growing neurodegenerative disorders in the developed world, with an increasing prevalence and associated socioeconomic costs. Progression of the disease leads to a gradual deterioration in patients' quality of life, despite optimal treatment, and both medical and societal needs increase, often with the assistance of paid and/or unpaid caregivers. OBJECTIVE We aimed to quantify the incremental economic burden of Parkinson's disease by disease severity in a real-world setting across differing geographic regions. METHODS Demographics, clinical characteristics, health status, patient quality of life, caregiver burden, and healthcare resource utilization data were drawn from the Adelphi Parkinson's Disease Specific Program™, conducted in the USA, five European countries, and Japan. RESULTS A total of 563 neurologists provided data for 5299 individuals with Parkinson's disease; 61% were male, with a mean age of 64 years. Approximately 15% of individuals were deemed to have advanced disease, with significantly more comorbidities, and a poorer quality of life, than those with non-advanced disease. Overall, the mean annual healthcare resource utilization increased significantly with advancing disease, and resulted in a three-fold difference in the USA and Europe. The main drivers behind the high economic burden included hospitalizations, prescription medications, and indirect costs. CONCLUSIONS People with Parkinson's disease, and their caregivers, incur a higher economic burden as their disease progresses. Future interventions that can control symptoms or slow disease progression could reduce the burden on people with Parkinson's disease and their caregivers, whilst also substantially impacting societal costs.
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Affiliation(s)
- K Ray Chaudhuri
- Parkinson Foundation Centre of Excellence, King's College Hospital and Kings College, London, UK.
| | - Jean-Philippe Azulay
- Department of Neurology and Movement Disorders, APHM Timone University Hospital and Institut de Neurosciences de la Timone, AMU-CNRS UMR 7289, Marseilles, France
| | - Per Odin
- University of Lund, Lund, Sweden
| | | | - Josefa Domingos
- Parkinson's Europe, Sevenoaks, UK
- Egas Moniz School of Health and Science, Almada, Portugal
| | | | | | | | | | | | | | | | - Pablo Martinez-Martin
- Center for Networked Biomedical Research in Neurodegenerative Diseases (CIBERNED), Carlos III Institute of Health, Madrid, Spain
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Constantin VA, Szász JA, Dulamea AO, Valkovic P, Kulisevsky J. Impact of Infusion Therapies on Quality of Life in Advanced Parkinson's Disease. Neuropsychiatr Dis Treat 2023; 19:1959-1972. [PMID: 37727253 PMCID: PMC10506606 DOI: 10.2147/ndt.s422717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/01/2023] [Indexed: 09/21/2023] Open
Abstract
A high burden of motor and non-motor parkinsonian symptoms is known to have a significant negative impact on the quality of life (QoL) of people with Parkinson's disease (PD). Effective control of these symptoms with therapies that enable patients to maintain a good QoL is therefore a key treatment goal in PD management. When symptom control can no longer be accomplished with oral or transdermal PD treatment regimens, device-aided therapies (DAT), namely levodopa and apomorphine infusion therapies, and deep brain stimulation, are valuable options to consider. DAT options may also help reduce pill burden and thereby improve compliance with treatment. Since PD therapy relies on symptomatic management, the efficacy and tolerability of any intervention is undoubtedly important, however the impact of different therapies on patient-related outcome measures, in particular health-related QoL, is also a critical consideration for those living with a chronic and disabling condition. This review discusses clinical evidence and ongoing research regarding the QoL benefits of levodopa and apomorphine infusion therapies from studies that have used validated QoL outcome measures. The data suggest that timing of these interventions is important to achieve optimal treatment effects, and that early initiation onto infusion therapies at the point when motor fluctuations emerge, and before patient QoL and functioning have significantly declined, may provide the best long-term outcomes. Healthcare professionals caring for people with PD should therefore discuss all available DAT options with them at an early stage in the course of their disease so they can make informed and timely choices that best suit them, their families and care network.
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Affiliation(s)
- Viorelia A Constantin
- Second Clinic of Neurology, Târgu Mures County Emergency Clinical Hospital, Târgu Mureș, Romania
| | - József A Szász
- Second Clinic of Neurology, Târgu Mures County Emergency Clinical Hospital, Târgu Mureș, Romania
- Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Târgu Mureș, Romania
| | - Adriana Octaviana Dulamea
- Neurology Clinic, Fundeni Clinical Institute, Bucharest, Romania
- University of Medicine and Pharmacy “Carol Davila” Bucharest, Bucharest, Romania
| | - Peter Valkovic
- Second Department of Neurology, Comenius University Faculty of Medicine and University Hospital Bratislava, Bratislava, Slovakia
| | - Jaime Kulisevsky
- Movement Disorders Unit at the Neurology Department of Sant Pau Hospital, Barcelona, Spain
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Thaler A, Barer Y, Gross R, Cohen R, Bergmann L, Jalundhwala YJ, Giladi N, Chodick G, Shalev V, Gurevich T. Long-Term Persistence and Monotherapy with Device-Aided Therapies: A Retrospective Analysis of an Israeli Cohort of Patients with Advanced Parkinson's Disease. Adv Ther 2022; 39:2009-2024. [PMID: 35247187 PMCID: PMC9056469 DOI: 10.1007/s12325-022-02072-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 02/02/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Patients with advanced Parkinson's disease (PD) may require device-aided therapies (DAT) for adequate symptom control. However, long-term, real-world efficacy and safety data are limited. This study aims to describe real-world, long-term treatment persistence for patients with PD treated with levodopa-carbidopa intestinal gel (LCIG). The study also aims to describe patient profiles, treatment discontinuation rates, co-medication patterns, monotherapy rates, and rates of healthcare visits and their associated costs for patients receiving all forms of DAT (deep brain stimulation [DBS], continuous subcutaneous apomorphine infusion [CSAI], or LCIG). METHODS In this retrospective analysis of the Israeli Maccabi Healthcare Services database, adult patients with PD were analyzed in three cohorts, based on DAT (DBS, CSAI, or LCIG). The primary endpoint was LCIG treatment persistence 12 months after initiation. RESULTS This analysis included 161 DAT-treated patients (LCIG, n = 62; DBS, n = 76; CSAI, n = 23). Among those who discontinued, the mean time to discontinuation was 86.4 months for LCIG and 42.4 months for CSAI (p = 0.046). Twelve months after initiation, 14.3% LCIG, 10.7% DBS, and 5.9% CSAI patients were not receiving any additional anti-parkinsonian therapy. At the last recorded visit, 28.6% LCIG, 13.3% DBS, and 5.9% CSAI patients received DAT as monotherapy. During the first 12 months after initiation, 45.2% LCIG, 65.2% CSAI, and 1.3% DBS patients had no reported hospitalization days. Annual healthcare visit costs decreased following LCIG initiation (US$9491 vs. $8146) and increased following DBS ($4113 vs. $7677) and CSAI ($6378 vs. $8277). CONCLUSION DAT are well maintained in patients with advanced PD. These retrospective data suggest that patients receiving LCIG may have higher long-term persistence rates compared with patients receiving CSAI. A subgroup of patients was treated with DAT as monotherapy without additional oral anti-parkinsonian therapy, with LCIG showing the highest rates.
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Affiliation(s)
- Avner Thaler
- Movement Disorders Unit, Neurological Institute, Tel Aviv Sourasky Medical Center, 6 Weizmann St, 64239, Tel Aviv, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.
| | - Yael Barer
- MaccabiTech, Maccabi Institute for Research and Innovation, Tel Aviv, Israel
| | | | | | | | | | - Nir Giladi
- Movement Disorders Unit, Neurological Institute, Tel Aviv Sourasky Medical Center, 6 Weizmann St, 64239, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Chodick
- MaccabiTech, Maccabi Institute for Research and Innovation, Tel Aviv, Israel
- School of Public Health, Tel Aviv University, Tel Aviv, Israel
| | - Varda Shalev
- MaccabiTech, Maccabi Institute for Research and Innovation, Tel Aviv, Israel
| | - Tanya Gurevich
- Movement Disorders Unit, Neurological Institute, Tel Aviv Sourasky Medical Center, 6 Weizmann St, 64239, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
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Windolf H, Chamberlain R, Breitkreutz J, Quodbach J. 3D Printed Mini-Floating-Polypill for Parkinson's Disease: Combination of Levodopa, Benserazide, and Pramipexole in Various Dosing for Personalized Therapy. Pharmaceutics 2022; 14:931. [PMID: 35631518 PMCID: PMC9145509 DOI: 10.3390/pharmaceutics14050931] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/19/2022] [Accepted: 04/22/2022] [Indexed: 01/27/2023] Open
Abstract
Therapy for Parkinson’s disease is quite challenging. Numerous drugs are available for symptomatic treatment, and levodopa (LD), in combination with a dopa decarboxylase inhibitor (e.g., benserazide (BZ)), has been the drug of choice for years. As the disease progresses, therapy must be supplemented with a dopamine agonist (e.g., pramipexole (PDM)). Side effects increase, as do the required dose and dosing intervals. For these specific requirements of drug therapy, the 3D printing method fused deposition modelling (FDM) was applied in this study for personalized therapy. Hot melt extrusion was utilized to produce two different compositions into filaments: PDM and polyvinyl alcohol for rapid drug release and a fixed combination of LD/BZ (4:1) in an ethylene-vinyl acetate copolymer matrix for prolonged drug release. Since LD is absorbed in the upper gastrointestinal tract, a formulation that floats in gastric fluid was desired to prolong API absorption. Using the FDM 3D printing process, different polypill geometries were printed from both filaments, with variable dosages. Dosage forms with 15−180 mg LD could be printed, showing similar release rates (f2 > 50). In addition, a mini drug delivery dosage form was printed that released 75% LD/BZ within 750 min and could be used as a gastric retentive drug delivery system due to the floating properties of the composition. The floating mini-polypill was designed to accommodate patients’ swallowing difficulties and to allow for individualized dosing with an API release over a longer period of time.
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Affiliation(s)
- Hellen Windolf
- Institute of Pharmaceutics and Biopharmaceutics, Heinrich Heine University, Universitätsstr. 1, 40225 Düsseldorf, Germany; (H.W.); (R.C.); (J.B.)
| | - Rebecca Chamberlain
- Institute of Pharmaceutics and Biopharmaceutics, Heinrich Heine University, Universitätsstr. 1, 40225 Düsseldorf, Germany; (H.W.); (R.C.); (J.B.)
| | - Jörg Breitkreutz
- Institute of Pharmaceutics and Biopharmaceutics, Heinrich Heine University, Universitätsstr. 1, 40225 Düsseldorf, Germany; (H.W.); (R.C.); (J.B.)
| | - Julian Quodbach
- Institute of Pharmaceutics and Biopharmaceutics, Heinrich Heine University, Universitätsstr. 1, 40225 Düsseldorf, Germany; (H.W.); (R.C.); (J.B.)
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
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Antonini A, Pahwa R, Odin P, Isaacson SH, Merola A, Wang L, Kandukuri PL, Alobaidi A, Yan CH, Bao Y, Zadikoff C, Parra JC, Bergmann L, Chaudhuri KR. Comparative Effectiveness of Device-Aided Therapies on Quality of Life and Off-Time in Advanced Parkinson's Disease: A Systematic Review and Bayesian Network Meta-analysis. CNS Drugs 2022; 36:1269-1283. [PMID: 36414908 PMCID: PMC9712309 DOI: 10.1007/s40263-022-00963-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Research comparing levodopa/carbidopa intestinal gel (LCIG), deep brain stimulation (DBS), and continuous subcutaneous apomorphine infusion (CSAI) for advanced Parkinson's disease (PD) is lacking. This network meta-analysis (NMA) assessed the comparative effectiveness of LCIG, DBS, CSAI and best medical therapy (BMT) in reducing off-time and improving quality of life (QoL) in patients with advanced PD. METHODS A systematic literature review was conducted for randomized controlled trials (RCTs), observational and interventional studies from January 2003 to September 2019. Data extracted at baseline and 6 months were off-time, as reported by diary or Unified Parkinson's Disease Rating Scale Part IV item 39, and QoL, as reported by Parkinson's Disease Questionnaire (PDQ-39/PDQ-8). Bayesian NMA was performed to estimate pooled treatment effect sizes and to rank treatments in order of effectiveness. RESULTS A total of 22 studies fulfilled the inclusion criteria (n = 2063 patients): four RCTs, and 16 single-armed, one 2-armed and one 3-armed prospective studies. Baseline mean age was between 55.5-70.9 years, duration of PD was 9.1-15.3 years, off-time ranged from 5.4 to 8.7 h/day in 9 studies, and PDQ scores ranged from 28.8 to 67.0 in 19 studies. Levodopa/carbidopa intestinal gel and DBS demonstrated significantly greater improvement in off-time and QoL at 6 months compared with CSAI and BMT (p < 0.05). There was no significant difference in the effects of LCIG and DBS, but DBS was ranked first for reduction in off-time, and LCIG was ranked first for improvement in QoL. CONCLUSIONS This NMA found that LCIG and DBS were associated with superior improvement in off-time and PD-related QoL compared with CSAI and BMT at 6 months after treatment initiation. This comparative effectiveness research may assist providers, patients, and caregivers in the selection of the optimal device-aided therapy.
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Affiliation(s)
- Angelo Antonini
- Parkinson and Movement Disorders Unit, Department of Neuroscience, Study Center for Neurodegeneration (CESNE), University of Padova, 35128, Padua, Italy.
| | - Rajesh Pahwa
- Medical Center, University of Kansas, Kansas City, KS USA
| | - Per Odin
- University of Lund, Lund, Sweden
| | | | - Aristide Merola
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Lin Wang
- AbbVie Inc., North Chicago, IL USA ,Johns Hopkins School of Public Health, Baltimore, MD USA
| | | | - Ali Alobaidi
- AbbVie Inc., North Chicago, IL USA ,University of Illinois at Chicago, Chicago, IL USA
| | - Connie H. Yan
- AbbVie Inc., North Chicago, IL USA ,University of Illinois at Chicago, Chicago, IL USA
| | | | | | | | | | - K. Ray Chaudhuri
- King’s College and Parkinson Foundation Centre of Excellence, Kings College Hospital London, London, UK
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Chaudhuri KR, Antonini A, Pahwa R, Odin P, Titova N, Thakkar S, Snedecor SJ, Hegde S, Alobaidi A, Parra JC, Zadikoff C, Bergmann L, Standaert DG. Effects of Levodopa-Carbidopa Intestinal Gel on Dyskinesia and Non-Motor Symptoms Including Sleep: Results from a Meta-Analysis with 24-Month Follow-Up. JOURNAL OF PARKINSON'S DISEASE 2022; 12:2071-2083. [PMID: 35964203 PMCID: PMC9661331 DOI: 10.3233/jpd-223295] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND In advanced Parkinson's disease (PD), dyskinesias and non-motor symptoms such as sleep dysfunction can significantly impair quality of life, and high-quality management is an unmet need. OBJECTIVE To analyze changes in dyskinesia and non-motor symptoms (including sleep) among studies with levodopa-carbidopa intestinal gel (LCIG) in patients with advanced PD. METHODS A comprehensive literature review identified relevant studies examining LCIG efficacy. Outcomes of interest were dyskinesia (UDysRS, UPDRS IV item 32), overall non-motor symptoms (NMSS), mentation/behavior/mood (UPDRS I), and sleep/daytime sleepiness (PDSS-2, ESS). The pooled mean (95% confidence interval) change from baseline per outcome was estimated for each 3-month interval with sufficient data (i.e., reported by≥3 studies) up to 24 months using a random-effects model. RESULTS Seventeen open-label studies evaluating 1243 patients with advanced PD were included. All outcomes of interest with sufficient data for meta-analysis showed statistically significant improvement within 6 months of starting LCIG. There were statistically significant improvements in dyskinesia duration as measured by UPDRS IV item 32 at 6 months (-1.10 [-1.69, -0.51] h/day) and 12 months (-1.35 [-2.07, -0.62] h/day). There were statistically and clinically significant improvements in non-motor symptoms as measured by NMSS scores at 3 months (-28.71 [-40.26, -17.15] points). Significant reduction of NMSS burden was maintained through 24 months (-17.61 [-21.52, -13.70] points). UPDRS I scores significantly improved at 3 months (-0.39 [-0.55, -0.22] points). Clinically significant improvements in PDSS-2 and ESS scores were observed at 6 and 12 months in individual studies. CONCLUSION Patients with advanced PD receiving LCIG showed significant sustained improvements in the burden of dyskinesia and non-motor symptoms up to 24 months after initiation.
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Affiliation(s)
- K. Ray Chaudhuri
- Parkinson Foundation Centre of Excellence, King’s College Hospital and King’s College, London, UK
- Correspondence to: K. Ray Chaudhuri, MBBS, MD, FRCP (Lond), FRCP (Edin), DSc, FEAN, Department of Basic and Clinical Neuroscience, The Maurice Wohl Clinical Neuroscience Institute, King’s College London, Cutcombe Road, London SE5 9RT, UK. Tel.: +44 0 7958249738; E-mail:
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Study Center for Neurodegeneration CESNE, Department of Neuroscience, University of Padova, Padova, Italy
| | - Rajesh Pahwa
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Per Odin
- University of Lund, Lund, Sweden
| | - Nataliya Titova
- N.I. Pirogov Russian National Research Medical University, Moscow, Russia
- Federal State Budgetary Institution «Federal center of brain research and neurotechnologies» of the Federal Medical Biological Agency, Moscow, Russia
| | | | | | | | - Ali Alobaidi
- AbbVie Inc., North Chicago, IL, USA
- University of Illinois at Chicago, Chicago, IL, USA
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Patient and caregiver outcomes with levodopa-carbidopa intestinal gel in advanced Parkinson’s disease. NPJ Parkinsons Dis 2021; 7:108. [PMID: 34848716 PMCID: PMC8633325 DOI: 10.1038/s41531-021-00246-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/07/2021] [Indexed: 01/02/2023] Open
Abstract
Levodopa-carbidopa intestinal gel (LCIG) has shown to be efficacious in motor and non-motor symptoms (NMS). Nevertheless, studies with patient Quality of Life (QoL) as a primary endpoint are scarce. To assess the effect of LCIG on Advanced Parkinson’s Disease (APD) patients QoL. Secondarily, the impact on motor symptoms and NMS, emotional well-being, treatment satisfaction, and caregiver QoL, stress, disease burden, anxiety, depression, and work impairment were also investigated. In this prospective, 6-month multicenter postmarketing observational study, LCIG was administered to 59 patients with APD. Endpoints were assessed using validated scales and questionnaires. LCIG significantly improved patient QoL (PDQ-39 mean change ± standard deviation from baseline, −12.8 ± 14.6; P < 0.0001), motor symptoms (UPDRS-III in “On,” −6.5 ± 11.8; P = 0.0002), NMS (NMSS, −35.7 ± 31.1; P < 0.0001), mood (Norris/Bond-Lader VAS, −6.6 ± 21.1; P = 0.0297), fatigue (PFS-16, −0.6 ± 1.0; P = 0.0003), depression (BDI-II, −5.1 ± 9.4; P = 0.0002), anxiety (BAI, −6.2 ± 9.6; P < 0.0001), and patient treatment satisfaction (SATMED-Q, 16.1 ± 16.8; P < 0.0001). There were significant correlations between the change from baseline to 6 months between PDQ-39 and UPDRS-IV, NMSS, BAI, BDI-II, AS, and PFS-16 scores, and Norris/Bond-Lader alertness/sedation factor. Caregiver anxiety also improved (Goldberg anxiety scale, −1.1 ± 1.0; P = 0.0234), but the clinical relevance of this finding is questionable. The serious adverse events reported were similar to those previously described for LCIG. In patients with APD, LCIG improves QoL, motor symptoms and NMS, emotional well-being, and satisfaction with the treatment. Improvement in patient QoL is associated with improvements in motor complications, NMS, anxiety, depression, apathy and fatigue. Improvements in patients’ QoL does not correspond with improvements in caregivers’ QoL or burden.
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Comparison of the Parkinson's KinetiGraph to off/on levodopa response testing: Single center experience. Clin Neurol Neurosurg 2021; 209:106890. [PMID: 34455169 DOI: 10.1016/j.clineuro.2021.106890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 07/13/2021] [Accepted: 08/08/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Levodopa off/on testing is frequently performed to assess medication response in patients with Parkinson's disease (PD) as an aid in determining best medical management or potential surgical candidacy. The Parkinson's Kinetigraph (PKG) is a wearable device which generates tremor, bradykinesia (BKS) and dyskinesia (DKS) scores representing motor symptoms over a six-day period. In this study, we compared off/on testing with PKG motor scores. METHODS Patients were enrolled as part of an observational study: Assessing the Longitudinal Signs in PD, a three-year study evaluating clinical and biomarker evolution in patients with PD taking levodopa. Patients underwent off/on testing at baseline and 6-month visits. A greater than 30% improvement between off and on MDS-Unified Parkinson's Disease Rating Scale scores was considered a robust response. After each visit, patients wore the PKG for 6 days. A bradykinesia score (BKS) greater than 26 and dyskinesia score (DKS) greater than 9 were considered poorly controlled bradykinesia and dyskinesia, respectively. RESULTS The median BKS at the baseline and 6-month visits were 27.15 and 27.55, respectively, despite a robust median off/on improvement at both visits. In addition, 10/18 (66%) and 7/13 (53.8%) patients with robust off/on improvement at the baseline and 6-month visits, respectively, demonstrated a BKS > 26 or DKS > 9. CONCLUSION A robust off/on response during a clinic visit does not necessarily reflect adequately controlled motor symptoms. The PKG, by virtue of its continuous recording of motor movements, may provide additional clinically relevant data on motor symptoms which may be useful for prospective observational studies.
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Norlin JM, Willis M, Persson U, Andersson E, Pålhagen S, Odin P. Swedish guidelines for device-aided therapies in Parkinson's disease -Economic evaluation and implementation. Acta Neurol Scand 2021; 144:170-178. [PMID: 33899213 DOI: 10.1111/ane.13434] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The National Board of Health and Welfare in Sweden published the national guidelines for Parkinson's Disease 2016. The aim of this study was to summarize this evidence review and development of the guidelines, focusing on the economic evaluation of device-aided therapies (deep brain stimulation, pump-based infusion of levodopa-carbidopa intestinal gel or apomorphine) for Parkinson's disease, and the rate of implementation after 3 years in Sweden. MATERIAL AND METHODS The evidence review underlying the guidelines-including systematic literature searches of clinical and economic evidence, model-based economic evaluation, and formal analysis and guideline development-was examined, condensed, and translated. The impact of the guidelines was assessed with treatment use statistics from 2009 to 2019. RESULTS All device-aided therapies were assigned high priority. Based on a relatively low proportion of device-aided therapies (30%) in Parkinson's disease, a 5-year increase of 500 patients was recommended. This was estimated to reduce total costs by SEK 14 million (€1.7 million). Follow-up data found an increase of 217 patients between 2017 and 2019, following the same trend as before the guidelines. CONCLUSION Three years after the guidelines were published, the use of device-aided therapies has increased in Sweden, albeit not in pace with recommendations. One reason for slow implementation may be poor incentivization related to budget silos in which the costs for device-aided therapies are borne by the regions but the cost offsets (eg, reduced need for home care) are reaped by local stakeholders.
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Affiliation(s)
| | | | - Ulf Persson
- The Swedish Institute for Health Economics Lund Sweden
| | | | - Sven Pålhagen
- Division of Neurology Department of Clinical Neuroscience Karolinska Institutet Stockholm Sweden
- Department of Neurology, Rehabilitation Medicine, Memory Disorders, and Geriatrics Skåne University Hospital Malmö Sweden
| | - Per Odin
- Department of Neurology, Rehabilitation Medicine, Memory Disorders, and Geriatrics Skåne University Hospital Malmö Sweden
- Restorative Parkinson Unit Division of Neurology Department of Clinical Sciences Lund Lund University Lund Sweden
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Standaert DG, Patel V, Snedecor SJ, Thakkar S, Jalundhwala YJ, Kukreja P, Kratochvil D, Bao Y, Pahwa R. Impact of carbidopa-levodopa enteral suspension on quality of life and activities of daily living in patients with advanced Parkinson's disease: Results from a pooled meta-analysis. Parkinsonism Relat Disord 2021; 86:52-57. [PMID: 33857722 DOI: 10.1016/j.parkreldis.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/19/2021] [Accepted: 03/10/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION To estimate the impact of carbidopa/levodopa enteral suspension (CLES) on key patient-centered outcomes in patients with advanced Parkinson's disease (PD). METHODS A comprehensive literature review identified relevant studies, from which data were meta-analyzed over 3-month intervals up to 24 months. Patient-centered outcomes of interest included mean (95% CI) changes from baseline (Δ) in quality of life (QoL), measured using PD-specific (PDQ-8, PDQ-39) and generic (EQ-5D) instruments; activities of daily living (ADL), measured in On and Off states using UPDRS Part II; and motor symptoms (i.e., Off time/day and motor examination [measured in On and Off states using UPDRS Part III]). RESULTS The pooled meta-analysis included data from 26 studies evaluating 1556 patients on CLES. At 3 months, all outcomes showed significant improvement: QoL (ΔPDQ-39 = -10.26 [-11.54, -8.97], ΔEQ-5DVAS = 15.42 [12.58, 18.26]); ADL (ΔUPDRS IION = -4.32 [-5.63, -3.01]); motor symptoms (ΔOff time hours/day = -3.48 [-4.15, -2.82], ΔUPDRS IIION = -6.20 [-9.88, -2.51]). At 24 months, there were statistically significant mean improvements in QoL (ΔPDQ-39 = -7.74 [-12.40, -3.07], ΔEQ-5DVAS = 11.18 [6.90, 15.45]) and ADL (ΔUPDRS IIOFF = -3.88 [-5.34, -2.42]), and Off time (-4.21 [-5.16, -3.26] hours/day). CONCLUSIONS Impact of CLES on significantly reducing Off time/day was observed to be rapid and durable (i.e., remained consistent across 24 months). Most QoL and ADL measures showed a consistent pattern of improvement with initiation of treatment and remained significantly improved from baseline at 24 months.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Rajesh Pahwa
- University of Kansas Medical Center, Kansas City, KS, USA.
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Smilowska K, van Wamelen DJ, Pietrzykowski T, Calvano A, Rodriguez-Blazquez C, Martinez-Martin P, Odin P, Chaudhuri KR. Cost-Effectiveness of Device-Aided Therapies in Parkinson's Disease: A Structured Review. JOURNAL OF PARKINSONS DISEASE 2021; 11:475-489. [PMID: 33386813 PMCID: PMC8150660 DOI: 10.3233/jpd-202348] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: Despite optimal dopaminergic treatment most patients in moderate to advanced stages of Parkinson’s disease (PD) experience progressively increasing disabilities, necessitating a shift from oral medication to device-aided therapies, including deep brain stimulation (DBS), intrajejunal levodopa-carbidopa infusion (IJLI), and continuous subcutaneous apomorphine infusion (CSAI). However, these therapies are costly, limiting their implementation. Objectives: To perform a systematic review on cost-effectiveness analyses for device-aided therapies in PD. Methods: References were identified by performing a systematic search in the PubMed and Web of Science databases in accordance with the PRISMA statement. In the absence of universal cost-effectiveness definitions, the gross domestic product per capita (GDP) in the country where a study was performed was used as a cut-off for cost-effectiveness based on cost per quality adjusted life year (QALY) gained. Results: In total 30 studies were retrieved. All device-aided therapies improved quality of life compared to best medical treatment, with improvements in QALYs between 0.88 and 1.26 in the studies with long temporal horizons. For DBS, nearly all studies showed that cost per QALY was below the GDP threshold. For infusion therapies only three studies showed a cost per QALY below this threshold, with several studies with long temporal horizons showing costs below or near the GDP threshold. Conclusion: Of the device-aided therapies, DBS can be considered cost-effective, but the majority of infusion therapy studies showed that these were less cost-effective. However, long-term use of the infusion therapies appears to improve their cost-effectiveness and in addition, several strategies are underway to reduce these high costs.
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Affiliation(s)
- Katarzyna Smilowska
- Silesian Center of Neurology, Katowice, Poland.,Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, the Netherlands
| | - Daniel J van Wamelen
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, the Netherlands.,Institute of Psychiatry, Psychology & Neuroscience, Department of Basic & Clinical Neuroscience, King's College London, London, United Kingdom.,Parkinson's Foundation Centre of Excellence at King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Tomasz Pietrzykowski
- Research Center for Public Policy and Regulatory Governance, Faculty of Law and Administration, University of Silesia, Katowice, Poland
| | - Alexander Calvano
- Institute of Psychiatry, Psychology & Neuroscience, Department of Basic & Clinical Neuroscience, King's College London, London, United Kingdom.,Parkinson's Foundation Centre of Excellence at King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Carmen Rodriguez-Blazquez
- National Center of Epidemiology and Center for Networked Biomedical Research in Neurodegenerative Diseases (CIBERNED), Carlos III Institute of Health, Madrid, Spain
| | - Pablo Martinez-Martin
- National Center of Epidemiology and Center for Networked Biomedical Research in Neurodegenerative Diseases (CIBERNED), Carlos III Institute of Health, Madrid, Spain
| | - Per Odin
- University of Lund, Faculty of Medicine, Lund, Sweden
| | - K Ray Chaudhuri
- Institute of Psychiatry, Psychology & Neuroscience, Department of Basic & Clinical Neuroscience, King's College London, London, United Kingdom.,Parkinson's Foundation Centre of Excellence at King's College Hospital NHS Foundation Trust, London, United Kingdom
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12
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Nijhuis FAP, Esselink R, de Bie RMA, Groenewoud H, Bloem BR, Post B, Meinders MJ. Translating Evidence to Advanced Parkinson's Disease Patients: A Systematic Review and Meta-Analysis. Mov Disord 2021; 36:1293-1307. [PMID: 33797786 PMCID: PMC8252410 DOI: 10.1002/mds.28599] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/02/2021] [Accepted: 03/01/2021] [Indexed: 12/19/2022] Open
Abstract
In the advanced stages of Parkinson's disease (PD), patients frequently experience disabling motor complications. Treatment options include deep brain stimulation (DBS), levodopa‐carbidopa intestinal gel (LCIG), and continuous subcutaneous apomorphine infusion (CSAI). Choosing among these treatments is influenced by scientific evidence, clinical expertise, and patient preferences. To foster patient engagement in decision‐making among the options, scientific evidence should be adjusted to their information needs. We conducted a systematic review from the patient perspective. First, patients selected outcomes for a treatment choice: quality of life, activities of daily living, ON and OFF time, and adverse events. Second, we conducted a systematic review and meta‐analysis for each treatment versus best medical treatment using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Finally, the evidence was transformed into comprehensible and comparable information. We converted the meta‐analysis results into the number of patients (per 100) who benefit clinically from an advanced treatment per outcome, based on the minimal clinically important difference and the cumulative distribution function. Although this approach allows for a comparison of outcomes across the three device‐aided therapies, they have never been compared directly. The interpretation is hindered by the relatively short follow‐up time in the included studies, usually less than 12 months. These limitations should be clarified to patients during the decision‐making process. This review can help patients integrate the evidence with their own preferences, and with their clinician's expertise, to reach an informed decision. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
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Affiliation(s)
- Frouke A P Nijhuis
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands.,Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, the Netherlands
| | - Rianne Esselink
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, the Netherlands
| | - Rob M A de Bie
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Hans Groenewoud
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bastiaan R Bloem
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, the Netherlands
| | - Bart Post
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, the Netherlands
| | - Marjan J Meinders
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, the Netherlands
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13
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Zhang CL, Han QW, Chen NH, Yuan YH. Research on developing drugs for Parkinson's disease. Brain Res Bull 2020; 168:100-109. [PMID: 33387636 DOI: 10.1016/j.brainresbull.2020.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/22/2020] [Accepted: 12/26/2020] [Indexed: 12/28/2022]
Abstract
Current treatments for Parkinson's disease (PD) are mainly dopaminergic drugs. However, dopaminergic drugs are only symptomatic treatments and limited by several side effects. Recent studies into drug development focused on emerging new molecular mechanisms, including nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, nuclear receptor-related 1 (Nurr1), adenosine receptor A2, nicotine receptor, metabotropic glutamate receptors (mGluRs), and glucocerebrosidase (GCase). Also, immunotherapy and common pathological mechanisms shared with Alzheimer's Disease (AD) and diabetes have attracted much attention. In this review, we summarized the development of preclinical and clinical studies of novel drugs and the improvement of dopaminergic drugs to provide a prospect for PD treatment.
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Affiliation(s)
- Cheng-Lu Zhang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica& Neuroscience Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Qi-Wen Han
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica& Neuroscience Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - Nai-Hong Chen
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica& Neuroscience Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China.
| | - Yu-He Yuan
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica& Neuroscience Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China.
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14
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Poewe W, Bergmann L, Robieson WZ, Antonini A. Predictors of Response for "Off" Time Improvement With Levodopa-Carbidopa Intestinal Gel Treatment: An Analysis of the GLORIA Registry. Front Neurol 2020; 11:419. [PMID: 32636792 PMCID: PMC7318911 DOI: 10.3389/fneur.2020.00419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/22/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Levodopa-carbidopa intestinal gel (LCIG) is a long-term therapy for motor fluctuations in patients with advanced Parkinson's disease (PD). The aim of this analysis was to identify the baseline characteristics that predict “Off” time reduction in advanced PD patients treated with LCIG under routine clinical care in the GLORIA registry. Methods: Patients were followed under routine care for 24 months (M) with delivery of LCIG via percutaneous gastrojejunostomy. Analysis of covariance (ANCOVA) and logistic regression were performed to identify baseline characteristics that predict “Off” time reduction. Results: Compared to baseline, 86% (n/N = 131/152; mean ± SD baseline “Off” time: 3.4 ± 2.2 h) of M24 completers had ≥ 1 h reduction in “Off” time and 64% (n/N = 97/152; mean ± SD baseline “Off” time: 7.6 ± 2.9 h) had ≥ 3 h “Off” time reduction at M24. Most baseline characteristics were similar across responder subgroups; however, patients with ≥ 3 h “Off” time improvement had more “Off” time and less time with dyskinesia at baseline compared to patients with <3 h “Off” time reduction. Despite having less improvement in absolute “Off” h at M24, patients with <3 h “Off” time reduction experienced a 33% median reduction in “Off” time and a 44% median reduction in dyskinesia duration at M24, which was similar to the dyskinesia improvement observed among patients with ≥ 3 h “Off” time improvement (50% median reduction). Baseline “Off” time was both the best predictor of and the only significant factor associated with “Off” time improvement (P <0.0001). Conclusions: LCIG treatment led to clinically meaningful improvements in “Off” time in 86% of advanced PD patients and those with greater “Off” time are likely to experience the largest absolute reduction in hours “Off.”
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Affiliation(s)
- Werner Poewe
- Medical University of Innsbruck, Innsbruck, Austria
| | | | | | - Angelo Antonini
- Department of Neuroscience, University of Padua, Padua, Italy
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15
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Mohadeseh Safaei, Beitollahi H, Shishehbore MR. Electrochemical Sensing of Levodopa in Presence of Tryptophan Using Modified Graphite Screen Printed Electrode with Magnetic Core-Shell Fe3O4@SiO2/GR Nanocomposite. SURFACE ENGINEERING AND APPLIED ELECTROCHEMISTRY 2020. [DOI: 10.3103/s1068375520020143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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16
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Antonini A, Marano P, Gusmaroli G, Modugno N, Pacchetti C, Sensi M, Melzi G, Bergmann L, Zibetti M, Lopiano L. Long-term effectiveness of levodopa-carbidopa intestinal gel on motor and non-motor symptoms in advanced Parkinson's disease: results of the Italian GLORIA patient population. Neurol Sci 2020; 41:2929-2937. [PMID: 32342325 PMCID: PMC7479015 DOI: 10.1007/s10072-020-04401-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/07/2020] [Indexed: 12/29/2022]
Abstract
Introduction The GLORIA registry included 375 advanced Parkinson’s disease (PD) patients and evaluated the efficacy and safety of a 24-month levodopa-carbidopa intestinal gel (LCIG) treatment in routine medical care. This analysis focuses on the Italian population, 60 patients treated with LCIG in 7 specialised PD care centres. Methods Hours of “Off” and “On” time were assessed with a modified version of the Unified Parkinson’s Disease Rating Scale (UPDRS) part IV items 39 and 32. Motor fluctuations, dyskinesia, non-motor symptoms, quality of life and safety were evaluated. Results Overall, 42 (70%) out of 60 patients completed the registry. LCIG treatment reduced “Off” time (− 3.3 ± 2.7 h at month 24 (M24), P < 0.0001), increased “On” time with dyskinesia (− 2.6 ± 5.2 h at M12, P = 0.0160), and improved UPDRS II and UPDRS III total scores at M24 (− 4.5 ± 10.6, P = 0.0333 and − 4.9 ± 11.7, P = 0.0229, respectively), Non-Motor Symptom Scale (NMSS) total score (− 21.8 ± 28.5, P < 0.0001) and Parkinson’s Disease Questionnaire-8 item (PDQ-8) total score (− 12.5 ± 23.9, P = 0.0173) versus previous oral therapy. Adverse drug reactions (ADR) possibly or probably related to treatment were reported in 16 (28.6%) patients. Decreased weight (7.1%), polyneuropathy (7.1%) and abdominal pain (5.4%) were the most frequent ADRs while device malfunction (5.4%) and medical device change (5.4%) were the most reported device complaints. Conclusions LCIG improved motor fluctuations, non-motor symptoms and quality of life over 24 months while tolerability was consistent with the established safety profile.
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Affiliation(s)
- Angelo Antonini
- Parkinson and Movement Disorders Unit, Department of Neuroscience, University of Padua, Padua, Italy.
| | | | | | | | - Claudio Pacchetti
- Parkinson's Disease and Movement Disorders Unit, IRCCS C. Mondino Foundation, Pavia, Italy
| | | | - Gabriella Melzi
- Medical Department, AbbVie s.r.l., Campoverde di Aprilia, Italy
| | | | - Maurizio Zibetti
- Department of Neuroscience, University of Torino, AOU Città della Salute e della Scienza, Torino, Italy
| | - Leonardo Lopiano
- Department of Neuroscience, University of Torino, AOU Città della Salute e della Scienza, Torino, Italy
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17
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The TANDEM investigation: efficacy and tolerability of levodopa-carbidopa intestinal gel in (LCIG) advanced Parkinson's disease patients. J Neural Transm (Vienna) 2020; 127:881-891. [PMID: 32212015 DOI: 10.1007/s00702-020-02175-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/09/2020] [Indexed: 01/18/2023]
Abstract
The TANDEM investigation was carried out in 17 Italian Movement Disorder centers on behalf of a joint initiative of neurologist members of the Italian Academy for Parkinson's disease and Movement Disorders (LIMPE-DISMOV Academy) and gastroenterologist members of the Italian Society of Digestive Endoscopy (SIED) to evaluate the efficacy and tolerability of levodopa-carbidopa intestinal gel (LCIG) in patients with advanced Parkinson's disease (PD) in routine medical care. Motor scores in "ON" and OFF" state (UPDRS-III), complications of therapy (UPDRS-IV), activities of daily living, sleep disorders and quality of life were evaluated at baseline and at two follow-up assessments (FUV1 and FUV2) within the initial 12-month LCIG treatment. In 159 patients (55% males) with a mean age of 69.1 ± 6.6 years and a diagnosis of PD since 13.6 ± 5.5 years, the UPDRS-III total score (in "OFF") decreased from baseline (45.8 ± 13.2) to FUV1 (41.0 ± 17.4; p < 0.001) and FUV2 (40.5 ± 15.5; p < 0.001), the UPDRS-IV total score decreased from baseline (8.8 ± 2.9) to FUV1 (5.1 ± 3.4; p < 0.001) and FUV2 (5.5 ± 3.2; p < 0.001). The percentage of patients exhibiting freezing, dystonia, gait/walking disturbances, falls, pain and sleep disorders was significantly reduced. Twenty-eight device complications were reported and 11 (6.9%) patients prematurely terminated the study. LCIG after 12-month treatment led to sustained improvement of time spent in "OFF", complications of therapy, PD-associated symptoms and sleep disorders. LCIG tolerability was consistent with the established safety profile of LCIG.
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18
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Shih TM, Sail KR, Jalundhwala YJ, Sullivan J, van Eijndhoven E, Zadikoff C, Marshall TS, Lakdawalla DN. The effect of functional status impairment on nursing home admission risk among patients with advanced Parkinson's disease. J Med Econ 2020; 23:297-307. [PMID: 31779508 DOI: 10.1080/13696998.2019.1693383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aims: To estimate the relationship between functional status (FS) impairment and nursing home admission (NHA) risk in Parkinson's disease (PD) patients, and quantify the effect of advanced PD (APD) treatment on NHA risk relative to standard of care (SoC).Materials and methods: PD patients were identified in the Medicare Current Beneficiary Survey (MCBS) (1992-2010). A working definition based on the literature and clinical expert input determined APD status. A logit model estimated the relationship between FS impairment and NHA risk. The effect of levodopa-carbidopa intestinal gel (LCIG) on NHA risk relative to SoC was simulated using clinical trial data (control: optimized oral levodopa-carbidopa IR, ClinicalTrials.gov NCT00660387 and NCT0357994).Results: Non-advanced PD and APD significantly increased NHA risk when controlling for demographics (p < 0.01). APD status was no longer significant after controlling for FS limitations, implying that FS limitations explain the increased NHA risk in APD patients. Reduced impairment in FS in patients with APD treated with LCIG reduced risk of NHA by 13.5% relative to SoC.Limitations: This study applies clinical trial results to real-world data. LCIG treatment might have a different effect on NHA risk for the nationally representative population than the effect measured in the trial. Both data sources employ different instruments to measure FS, instrument wording and study follow-up differed, which might bias our estimates. Finally, there lacks consensus on a definition of APD. The prevalence of APD in this study is high, perhaps due to the specific definition used.Conclusions: Patients with APD experience a higher risk in NHA than those with non-advanced disease. This increased risk in NHA in patients with APD is explained by greater limitations in FS. The relative reduction in risk of NHA for the APD population treated with LCIG is quantitatively similar to doubling Medicaid home care services.
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Affiliation(s)
| | | | | | | | | | - Cindy Zadikoff
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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19
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20
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Wang AS, Gunzler SA. Systematic review of the pharmacoeconomics of Parkinson disease medications. Expert Opin Pharmacother 2019; 20:1659-1670. [DOI: 10.1080/14656566.2019.1622091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Alexander S. Wang
- Neurological Institute, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Steven A. Gunzler
- Neurological Institute, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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21
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Torkzadeh-Mahani R, Foroughi MM, Jahani S, Kazemipour M, Hassani Nadiki H. The effect of ultrasonic irradiation on the morphology of NiO/Co 3O 4 nanocomposite and its application to the simultaneous electrochemical determination of droxidopa and carbidopa. ULTRASONICS SONOCHEMISTRY 2019; 56:183-192. [PMID: 31101254 DOI: 10.1016/j.ultsonch.2019.04.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/26/2019] [Accepted: 04/01/2019] [Indexed: 06/09/2023]
Abstract
The present work deals with the preparation of NiO/Co3O4 nanocomposites in presence of ultrasonic irradiation, and its use in electrochemical determination of Parkinson's drugs. NiO/Co3O4 nanocomposites are prepared using ultrasound assisted method. The impact of ultrasonic irradiation power (0, 75, 150, 300 and 600 W) on the structure and morphology of NiO/Co3O4 nanocomposites was investigated. Various particle morphologies were attained because of the existence of ultrasonic irradiation. The nanoparticles' structure exhibited more uniformity whilst the particles sizes and nanoparticle accumulation was reduced when ultrasonic irradiation power was increased. The NiO/Co3O4 nanocomposite was determined via X-ray diffraction, scanning electron microscopy i.e. SEM as well as energy dispersion X-ray spectroscopy (EDX). Drop casting NiO/Co3O4 nanocomposites suspension on glassy carbon electrode was employed to fabricate the modified glassy carbon electrode (NiO/Co3O4/GCE). The electrochemical studies on the NiO/Co3O4 nanocomposite towards droxidopa and carbidopa were experimented via cyclic voltammetry (CV), chronoamperometry (CHA) and differential pulse voltammetry (DPV). The CV examinations displayed increased catalytic behavior of droxidopa because of synergistic impact of the nanocomposite that was bolstered through enhanced material surface roughness. By using differential pulse voltammetry, the droxidopa detection limit and linear range was determined as 0.01 μM and 0.1-500.0 μM, respectively. Also, the adjusted electrode was implemented to ascertain droxidopa in the presence of carbidopa by differential pulse voltammetry. This sensor exhibited long term reproducibility and stability. Droxidopa and carbidopa quantification within biological specimens of fluids i.e. human urine and serum were conducted to validate the suitability in the application of this sensor.
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Affiliation(s)
| | | | - Shohreh Jahani
- NanoBioElectrochemistry Research Center, Bam University of Medical Sciences, Bam, Iran; Student Research Committee, School of Public Health, Bam University of Medical Sciences, Bam, Iran
| | - Maryam Kazemipour
- Department of Chemistry, Kerman Branch, Islamic Azad University, Kerman, Iran
| | - Hadi Hassani Nadiki
- Department of Chemistry, Kerman Branch, Islamic Azad University, Kerman, Iran
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Kalabina S, Belsey J, Pivonka D, Mohamed B, Thomas C, Paterson B. Cost-utility analysis of levodopa carbidopa intestinal gel (Duodopa) in the treatment of advanced Parkinson's disease in patients in Scotland and Wales. J Med Econ 2019; 22:215-225. [PMID: 30484353 DOI: 10.1080/13696998.2018.1553179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AIMS To carry out a cost-utility analysis comparing the cost-effectiveness of levodopa carbidopa intestinal gel (LCIG) with standard of care (SOC) in patients with advanced Parkinson's Disease (aPD) unsuitable for apomorphine or deep brain stimulation (DBS). LCIG is the only treatment option in this small, but clinically important, population. METHODS A Markov model with 25 disease states based on disease stage and off-time status plus death. Patients enter the model with aPD spending >50% of their waking day in the off-state. Patients progress through the model in 6-monthly cycles for 20 years to approximate lifetime treatment and capture long-term costs and effects of therapy. Inputs are based on LCIG clinical trials for clinical outcomes and health state utilities, the literature for health state transitions and use UK-based input data wherever possible (drug costs, disease/adverse event management costs, discontinuation rates, mortality rates). LIMITATIONS Data collection can be challenging in this small, elderly population with advanced disease, therefore some model inputs were estimated, rather than collected directly. It was assumed that a reduction in off-time was the only benefit after the first year of treatment with LCIG; this is a conservative approach, since there may be additional clinical benefits. RESULTS There is a considerable incremental gain in quality adjusted life years (QALYs) for patients treated with LCIG of 1.26 QALY with an associated incremental cost-effectiveness ratio (ICER) of £52,110. If the impact on caregivers is included, the ICER reduces to £47,266. CONCLUSIONS In cases where there is an orphan population, with no alternative treatment options, HTA assessments have a broader decision-making framework and the ICER is interpreted in this context. In the setting of a very small population, with considerable unmet need, LCIG represents value for money, as reflected by funding approval across the UK.
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Affiliation(s)
| | | | | | - Biju Mohamed
- c Cardiff and Vale University Health Board , Cardiff , UK
| | - Chris Thomas
- c Cardiff and Vale University Health Board , Cardiff , UK
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Thomas I, Memedi M, Westin J, Nyholm D. The effect of continuous levodopa treatment during the afternoon hours. Acta Neurol Scand 2019; 139:70-75. [PMID: 30180267 DOI: 10.1111/ane.13020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/13/2018] [Accepted: 08/24/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The aim of this retrospective study was to investigate whether patients with Parkinson's disease, who are treated with levodopa-carbidopa intestinal gel (LCIG), clinically worsen during the afternoon hours and if so, to evaluate whether this occurs in all LCIG-treated patients or in a subgroup of patients. METHODS Three published studies were identified and included in the analysis. All studies provided individual response data assessed on the treatment response scale (TRS), and patients were treated with continuous LCIG. Ninety-eight patients from the three studies fulfilled the criteria. t tests were performed to find differences on the TRS values between the morning and the afternoon hours, linear mixed effect models were fitted on the afternoon hours' evaluations to find trends of wearing-off, and patients were classified into three TRS categories (meaningful increase in TRS, meaningful decrease in TRS, non-meaningful increase or decrease). RESULTS In all three studies, significant statistical differences were found between the morning TRS values and the afternoon TRS values (P-value <=0.001 in all studies). The linear mixed effect models had significant negative coefficients for time in two studies, and 48 out of 98 patients (49%) showed a meaningful decrease in TRS during the afternoon hours. CONCLUSION The results from all studies were consistent, both in the proportion of patients in the three groups and in the value of TRS decrease in the afternoon hours. Based on these findings, there seems to be a group of patients with predictable "off" behavior in the later parts of the day.
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Affiliation(s)
- Ilias Thomas
- Department of Micro-data Analysis; Dalarna University; Falun Sweden
| | | | - Jerker Westin
- Department of Micro-data Analysis; Dalarna University; Falun Sweden
| | - Dag Nyholm
- Department of Neuroscience, Neurology; Uppsala University; Uppsala Sweden
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24
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Ray Chaudhuri K, Antonini A, Robieson WZ, Sanchez-Soliño O, Bergmann L, Poewe W. Burden of non-motor symptoms in Parkinson's disease patients predicts improvement in quality of life during treatment with levodopa-carbidopa intestinal gel. Eur J Neurol 2018; 26:581-e43. [PMID: 30353942 PMCID: PMC6590168 DOI: 10.1111/ene.13847] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 10/12/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND PURPOSE GLORIA, a registry conducted with 375 advanced Parkinson's disease patients treated with levodopa-carbidopa intestinal gel (LCIG) for 24 months in routine clinical care, demonstrated significant reductions from baseline in 'off' time and 'on' time with dyskinesia and improvements in the Non-Motor Symptom Scale (NMSS) total and individual domain scores, and in Parkinson's Disease Questionnaire 8 item (PDQ-8) total score. METHODS Associations between baseline NMSS burden (NMSB), the multi-domain NMSS total score and the PDQ-8 total score were investigated for 233 patients. Baseline NMSB was assigned to five numerical categories defined by the NMSS total cutoff scores (0-20, 21-40, 41-60, 61-80 and >80). Pearson and Spearman correlations were calculated at month 24. RESULTS The response of LCIG was assessed using validated criteria after 24 months. The proportion of patients decreasing ≥ 30 NMSS score points was 47% in the most affected NMSB category (NMSS total score > 80). A positive association was noted between baseline NMSB and NMSS total score (0.57, P < 0.0001), as well as between NMSS total score and PDQ-8 total score (0.46, P < 0.0001). Associations between improvements of the NMSS domain sleep/fatigue and PDQ-8 total score (0.32, P = 0.0001) as well as between the NMSS domain mood/cognition and PDQ-8 total score (0.37, P < 0.0001) were also shown. CONCLUSIONS This analysis demonstrated positive associations between NMSS baseline burden and improvements of non-motor symptoms. Improvements of non-motor symptoms were associated with improved quality of life in advanced parkinsonian patients during a 2-year treatment with LCIG and reflect the long-term non-motor efficacy of this treatment.
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Affiliation(s)
- K Ray Chaudhuri
- Parkinson Foundation International Centre of Excellence, King's College Hospital, Denmark Hill, London, UK.,Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - A Antonini
- Department of Neuroscience, University of Padua, Padua, Italy
| | | | | | | | - W Poewe
- Medical University of Innsbruck, Innsbruck, Austria
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Agarwal P, Ray S, Burdick D, Griffith AF, Madan A. Efficacy and safety of ADS-5102 (amantadine) extended-release capsules for treating levodopa-induced dyskinesia. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1525532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Pinky Agarwal
- Booth Gardner Parkinson’s Center, Evergreen Neuroscience Institute, Kirkland, WA, USA
| | - Sudeshna Ray
- Booth Gardner Parkinson’s Center, Evergreen Neuroscience Institute, Kirkland, WA, USA
| | - Daniel Burdick
- Booth Gardner Parkinson’s Center, Evergreen Neuroscience Institute, Kirkland, WA, USA
| | - Alida F Griffith
- Booth Gardner Parkinson’s Center, Evergreen Neuroscience Institute, Kirkland, WA, USA
| | - Arina Madan
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, UK
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26
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Sensitive LC–MS/MS method for quantitation of levodopa and carbidopa in plasma: application to a pharmacokinetic study. Bioanalysis 2018; 10:1567-1576. [DOI: 10.4155/bio-2018-0112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aim: The combination of levodopa with carbidopa has been used for treatment of Parkinson's disease being an important therapy in dopamine level control in the brain. Both are very polar compounds becoming a challenge for analysis by LC–MS/MS.Materials & methods: In this work, it was developed and validated a sensitive bioanalytical method by UHPLC–MS/MS for simultaneous levodopa and carbidopa quantification in human plasma using a fast protein precipitation method. Moreover, the bioanalytical method was applied to a pharmacokinetic study in healthy volunteers. Results/Conclusion: The results demonstrated a sensitive and adequate method for application to pharmacokinetic/bioequivalence studies.
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27
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Wang L, Li J, Chen J. Levodopa-Carbidopa Intestinal Gel in Parkinson's Disease: A Systematic Review and Meta-Analysis. Front Neurol 2018; 9:620. [PMID: 30104997 PMCID: PMC6077236 DOI: 10.3389/fneur.2018.00620] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/10/2018] [Indexed: 01/11/2023] Open
Abstract
Background: Levodopa has been widely used and regarded as the most effective therapy for Parkinson's disease (PD), but long-term treatment with oral levodopa may result in motor fluctuations and involuntary movements (dyskinesias). There is evidence to suggest that Continuous infusion of levodopa-carbidopa intestinal gel (LCIG) can effectively manage motor and non-motor complications in PD, but clinical studies investigating this have yielded inconsistent results. This systematic review and meta-analysis was performed to examine the efficacy and safety of LCIG for patients with PD. Methods: A systematic search was conducted to retrieve published data in the EMBASE, PubMed, and the Cochrane Library up to March 2018. Both efficiency and safety of LCIG were analyzed using pooled standardized mean differences (SMDs) or odds ratio (ORs) with 95% confidence interval (CIs). Results: Eight trials with 384 PD patients were included in the present study. Compared with the control group, LCIG significantly decreased off-time (SMD, −1.19; 95% CI, −2.25 to −0.12; p = 0.003) and increased on-time without troublesome dyskinesia (SMD, 0.55; 95% CI, 0.20 to 0.90; p = 0.002). However, no significant difference of LCIG was found in on-time with troublesome dyskinesia. There were no significant differences in UPDRS, Hoehn & Yahr and PDQ-39 scores. Besides, no significant differences in the drop-out and adverse effects. Conclusions: Continuous delivery of LCIG may offer a promising option for PD patients. More randomized double-blind controlled studies with large sample sizes were needed to further confirm the efficacy and safety of LCIG for PD patients.
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Affiliation(s)
- Libo Wang
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jia Li
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jiajun Chen
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, China
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Antonini A, Robieson WZ, Bergmann L, Yegin A, Poewe W. Age/disease duration influence on activities of daily living and quality of life after levodopa-carbidopa intestinal gel in Parkinson's disease. Neurodegener Dis Manag 2018; 8:161-170. [DOI: 10.2217/nmt-2017-0046] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To determine if age and Parkinson's disease duration at therapy initiation influence the efficacy of levodopa-carbidopa intestinal gel (LCIG) on quality of life and activities of daily living. Patients & methods: This post hoc analysis assessed subgroups of patients stratified by baseline age, disease duration, hours/day of ‘off’ time and levodopa equivalent dose. Patients’ data were collected from the GLORIA study, a 24-month observational registry evaluating long-term effectiveness of LCIG. Results & conclusion: LCIG therapy led to sustained improvements in quality of life irrespective of patient age and disease duration at baseline. Improvements in activities of daily living were observed across all subgroups, particularly in younger patients, patients with shorter disease duration and in patients with the highest baseline levodopa equivalent dose.
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Affiliation(s)
- Angelo Antonini
- Department of Neuroscience, Padua University, Padua, 35122, Italy
| | | | | | | | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Innsbruck, A-6060, Austria
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Vijiaratnam N, Sue CM. Levodopa-carbidopa intestinal gel: 'dismantling the road blocks of a journey'. Intern Med J 2018; 48:472-474. [PMID: 29623993 DOI: 10.1111/imj.13757] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 01/23/2018] [Indexed: 01/15/2023]
Abstract
Levodopa-carbidopa intestinal gel offers superior treatment to standard oral therapy in selective patients with advanced Parkinson disease. The costs involved in instituting and maintaining this treatment are high but largely mitigated with the quality of life years the treatment offers. Key to this is ensuring a high retention rate once the treatment is instituted. We outline factors and considerations from our experience and viewpoints at each stage of the process to address in this 'journey' patients undertake that can help maximise retention rates and benefits.
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Affiliation(s)
| | - Carolyn M Sue
- Department of Neurogenetics and Centre of Excellence for Parkinson's Disease and Movement Disorders, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Fernandez HH, Boyd JT, Fung VSC, Lew MF, Rodriguez RL, Slevin JT, Standaert DG, Zadikoff C, Vanagunas AD, Chatamra K, Eaton S, Facheris MF, Hall C, Robieson WZ, Benesh J, Espay AJ. Long-term safety and efficacy of levodopa-carbidopa intestinal gel in advanced Parkinson's disease. Mov Disord 2018; 33:928-936. [DOI: 10.1002/mds.27338] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 01/09/2018] [Accepted: 01/11/2018] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - James T. Boyd
- University of Vermont Larner College of Medicine, Burlington; Vermont USA
| | | | - Mark F. Lew
- Keck/University of Southern California School of Medicine; Los Angeles California USA
| | - Ramon L. Rodriguez
- University of Florida College of Medicine, Gainesville, Florida, USA, and Orlando Veterans Affairs Medical Center; Orlando Florida USA
| | - John T. Slevin
- University of Kentucky Medical Center; Lexington Kentucky USA
| | | | - Cindy Zadikoff
- Feinberg School of Medicine; Northwestern University; Chicago Illinois USA
| | | | | | | | | | | | | | | | - Alberto J. Espay
- University of Cincinnati Academic Health Center; Cincinnati Ohio USA
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Murata M, Mihara M, Hasegawa K, Jeon B, Tsai CH, Nishikawa N, Oeda T, Yokoyama M, Robieson WZ, Chatamra K, Facheris MF, Benesh J. Safety and efficacy of levodopa-carbidopa intestinal gel: results from an open-label extension study in Japanese, Korean and Taiwanese patients with advanced Parkinson's disease. Ther Adv Neurol Disord 2018; 11:1756286418759315. [PMID: 29511383 PMCID: PMC5833238 DOI: 10.1177/1756286418759315] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 09/04/2017] [Indexed: 11/16/2022] Open
Abstract
Objectives: Levodopa-carbidopa intestinal gel (LCIG) was developed to reduce motor complications in Parkinson’s disease (PD) caused by pulsatile levodopa plasma concentrations following oral levodopa administration. Dyskinesia and ‘wearing off’ symptoms can vary between Asian and Caucasian patients with PD, thus highlighting the importance of assessing the effectiveness of LCIG in an Asian population. Efficacy and safety of LCIG were previously assessed in a 12-week open-label study; we report the efficacy and safety of at least 52 weeks of LCIG treatment in Japanese, Taiwanese, and Korean patients with advanced PD in the ongoing extension study. Methods: In this interim analysis of a phase III, open-label, multicenter extension study in Japan, South Korea, and Taiwan [ClinicalTrials.gov identifier: NCT02082249/JapiCTI-142482], the mean change from baseline to final visit in ‘off’ time, as reported in the PD symptom diary, was normalized to a 16-h waking day. Changes in Parkinson’s Disease Questionnaire-39 (PDQ-39) summary index and domains scores were also analyzed. Adverse events (AEs) were recorded. Results: Of the 28 patients enrolled (21 Japanese, 3 Taiwanese, 4 Korean), 27 completed at least 52 total weeks of treatment, and 25 patients were continuing in the study at data cutoff. The mean [standard deviation (SD)] ‘off’ time was significantly reduced by 4.6 (3.1) h/day (p < 0.001, n = 28). Patients experienced significant improvements in quality of life, as recorded by the mean change from baseline in PDQ-39 summary index (p < 0.001). All patients had at least one AE; three patients (11%) discontinued due to an AE. There were two deaths (sepsis and drowning), both of which the investigator considered unrelated to LCIG treatment. Conclusions: These data suggest that LCIG treatment is efficacious, safe, and well tolerated in Japanese, Taiwanese, and Korean patients with advanced PD, thus confirming the consistency of LCIG treatment in patients with advanced PD.
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Affiliation(s)
- Miho Murata
- National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira 187-8551, Tokyo, Japan
| | | | - Kazuko Hasegawa
- National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Beomseok Jeon
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Chon-Haw Tsai
- Department of Neurology, China Medical University Hospital Medical College, China Medical University, Taichung, Taiwan
| | | | - Tomoko Oeda
- National Hospital Organization Utano Hospital, Kyoto, Japan
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Thomas I, Alam M, Nyholm D, Senek M, Westin J. Individual dose-response models for levodopa infusion dose optimization. Int J Med Inform 2018; 112:137-142. [PMID: 29500011 DOI: 10.1016/j.ijmedinf.2018.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/26/2018] [Accepted: 01/30/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND OBJECTIVE To achieve optimal effect with continuous infusion treatment in Parkinson's disease (PD), the individual doses (morning dose and continuous infusion rate) are titrated by trained medical personnel. This study describes an algorithmic method to derive optimized dosing suggestions for infusion treatment of PD, by fitting individual dose-response models. The feasibility of the proposed method was investigated using patient chart data. METHODS Patient records were collected at Uppsala University hospital which provided dosing information and dose-response evaluations. Mathematical optimization was used to fit individual patient models using the records' information, by minimizing an objective function. The individual models were passed to a dose optimization algorithm, which derived an optimized dosing suggestion for each patient model. RESULTS Using data from a single day's admission the algorithm showed great ability to fit appropriate individual patient models and derive optimized doses. The infusion rate dosing suggestions had 0.88 correlation and 10% absolute mean relative error compared to the optimal doses as determined by the hospital's treating team. The morning dose suggestions were consistency lower that the optimal morning doses, which could be attributed to different dosing strategies and/or lack of on-off evaluations in the morning. CONCLUSION The proposed method showed promise and could be applied in clinical practice, to provide the hospital personnel with additional information when making dose adjustment decisions.
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Affiliation(s)
- Ilias Thomas
- Department of Micro-data analysis, Dalarna University, Falun, 79 131, Sweden.
| | - Moudud Alam
- Department of Micro-data analysis, Dalarna University, Falun, 79 131, Sweden
| | - Dag Nyholm
- Dept. of Neuroscience, Neurology, Uppsala University, Uppsala, 751 85, Sweden
| | - Marina Senek
- Dept. of Neuroscience, Neurology, Uppsala University, Uppsala, 751 85, Sweden
| | - Jerker Westin
- Department of Micro-data analysis, Dalarna University, Falun, 79 131, Sweden
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Catalán MJ, Antonini A, Calopa M, Băjenaru O, de Fábregues O, Mínguez-Castellanos A, Odin P, García-Moreno JM, Pedersen SW, Pirtošek Z, Kulisevsky J. Can suitable candidates for levodopa/carbidopa intestinal gel therapy be identified using current evidence? eNeurologicalSci 2017; 8:44-53. [PMID: 29260038 PMCID: PMC5730910 DOI: 10.1016/j.ensci.2017.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 06/26/2017] [Indexed: 01/24/2023] Open
Abstract
Advanced Parkinson's disease (APD) is characterized by increased functional disability, caused by motor complications, the presence of axial symptoms, and emergent disease- and drug-related non-motor symptoms. One of the advanced therapies available is intrajejunal infusion of levodopa/carbidopa intestinal gel (LCIG); however, patient selection for this treatment is sometimes difficult, particularly because of overlapping indications with other alternatives. In recent years, strong evidence has supported the use of LCIG in treating motor fluctuations associated with APD, and several clinical studies provide emerging evidence for additional benefits of LCIG treatment in certain patients. This article provides an overview of the published literature on the benefits, limitations, and drawbacks of LCIG in relation to PD symptoms, the psychosocial impact of the disease, and the quality of life of patients, with the aim of determining candidates for whom treatment with LCIG would be beneficial. According to current evidence, patients with APD (defined as inability to achieve optimal control of the disease with conventional oral treatment), a relatively well-preserved cognitive-behavioral status, and good family/caregiver would count as suitable candidates for LCIG treatment. Contraindications in the opinion of the authors are severe dementia and active psychosis.
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Key Words
- APD, Advanced Parkinson's disease
- DBS, Deep brain stimulation
- Duodopa
- ICD, Impulse control disorders
- Intrajejunal infusion of levodopa/carbidopa intestinal gel
- LCIG, Levodopa-carbidopa intestinal gel
- Motor symptoms
- NMS, Non-motor symptoms
- NMSS, Non-motor symptoms scale
- Non-motor symptoms
- PD, Parkinson's disease
- PDSS, Parkinson's disease sleep scale
- PEG, Percutaneous endoscopic gastrostomy
- Parkinson's disease
- QoL, Quality of life
- Quality of life
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Affiliation(s)
- Maria José Catalán
- Parkinson and Movement Disorders Unit, Hospital Clínico San Carlos, Madrid, Spain
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Department of Neurosciences, IRCCS Hospital San Camillo, Venice, Italy
| | | | - Ovidiu Băjenaru
- University of Medicine and Pharmacy "Carol Davila" Bucharest - University Emergency Hospital, Department of Neurology, Bucharest, Romania
| | - Oriol de Fábregues
- Vall d'Hebron University Hospital, Neurology Service, Movement Disorders Unit, Autonomous University of Barcelona, Neurodegenerative Diseases Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Adolfo Mínguez-Castellanos
- Complejo Hospitalario Universitario de Granada, Instituto de Investigación Biosanitaria "ibs. Granada,", Granada, Spain
| | - Per Odin
- Skåne University Hospital, Lund University, Lund, Sweden.,Klinikum-Bremerhaven, Bremerhaven, Germany
| | | | | | | | - Jaime Kulisevsky
- Hospital Santa Creu i Sant Pau, Ciberned, Universitat Autònoma de Barcelona, Universitat Oberta de Catalunya, Barcelona, Spain
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Antonini A, Poewe W, Chaudhuri KR, Jech R, Pickut B, Pirtošek Z, Szasz J, Valldeoriola F, Winkler C, Bergmann L, Yegin A, Onuk K, Barch D, Odin P, Amalia E, Arnold G, Bajenaru O, Bergmans B, Bjornara KA, Blackie J, Bode M, Bourgeois P, Bohlhalter S, Buraga I, Burkhard PR, Busson P, Calopa M, Clausen J, Danielsen EH, Defebvre L, Delvaux V, Dethy S, Dietrichs E, De Fabregues O, Gerhard R, Gusmaroli G, Hahn K, Hauptmann B, Henriksen T, Hernandez-Vara J, Jeanjean A, Kaiserova M, Kassubek J, Kimber T, Konitsiotis S, Krüger R, Kulisevsky J, Leenders J, Lundqvist C, Ory Magne F, Marano P, Milanov I, Modugno N, Misbahuddin A, Nevrly M, Panayiotis Z, Pedersen KF, Pedersen SW, Perju-Dumbrava L, Ponsen M, Popescu BO, Rijntjes M, Puente V, Redecker C, Schrader C, Sensi M, Simu M, Spanaki C, Storch A, Storstein A, Tomantschger V, van der Linden C, van Laar T, Viallet F, Witjas T, Wolz M, Zibetti M, Van Zandijcke M. Levodopa-carbidopa intestinal gel in advanced Parkinson's: Final results of the GLORIA registry. Parkinsonism Relat Disord 2017; 45:13-20. [DOI: 10.1016/j.parkreldis.2017.09.018] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/16/2017] [Accepted: 09/18/2017] [Indexed: 11/24/2022]
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Krüger R, Klucken J, Weiss D, Tönges L, Kolber P, Unterecker S, Lorrain M, Baas H, Müller T, Riederer P. Classification of advanced stages of Parkinson's disease: translation into stratified treatments. J Neural Transm (Vienna) 2017; 124:1015-1027. [PMID: 28342083 PMCID: PMC5514193 DOI: 10.1007/s00702-017-1707-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/11/2017] [Indexed: 01/07/2023]
Abstract
Advanced stages of Parkinson's disease (advPD) still impose a challenge in terms of classification and related stage-adapted treatment recommendations. Previous concepts that define advPD by certain milestones of motor disability apparently fall short in addressing the increasingly recognized complexity of motor and non-motor symptoms and do not allow to account for the clinical heterogeneity that require more personalized approaches. Therefore, deep phenotyping approaches are required to characterize the broad-scaled, continuous and multidimensional spectrum of disease-related motor and non-motor symptoms and their progression under real-life conditions. This will also facilitate the reasoning for clinical care and therapeutic decisions, as neurologists currently have to refer to clinical trials that provide guidance on a group level; however, this does not always account for the individual needs of patients. Here, we provide an overview on different classifications for advPD that translate into critical phenotypic patterns requiring the differential therapeutic adjustments. New concepts refer to precision medicine approaches also in PD and first studies on genetic stratification for therapeutic outcomes provide a potential for more objective treatment recommendations. We define novel treatment targets that align with this concept and make use of emerging device-based assessments of real-life information on PD symptoms. As these approaches require empowerment of patients and integration into treatment decisions, we present communication strategies and decision support based on new technologies to adjust treatment of advPD according to patient demands and safety.
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Affiliation(s)
- Rejko Krüger
- Luxembourg Centre for Systems Biomedicine (LCSB), University of Luxembourg, Esch-Sur-Alzette, Luxembourg.
- Centre Hospitalier de Luxembourg (CHL), Luxembourg, Luxembourg.
| | - Jochen Klucken
- Molecular Neurology, University of Erlangen, Erlangen, Germany
| | - Daniel Weiss
- Department for Neurodegenerative Diseases and Hertie-Institute for Clinical Brain Research, Center for Neurology, University of Tübingen, Tübingen, Germany
| | - Lars Tönges
- Department of Neurology of the Ruhr-University Bochum at St Josef-Hospital, Gudrunstrasse 56, 44791 , Bochum, Germany
| | - Pierre Kolber
- Luxembourg Centre for Systems Biomedicine (LCSB), University of Luxembourg, Esch-Sur-Alzette, Luxembourg
- Centre Hospitalier de Luxembourg (CHL), Luxembourg, Luxembourg
| | - Stefan Unterecker
- Center of Mental Health, Clinic and Policlinic of Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Würzburg, Germany
| | | | - Horst Baas
- Department of Neurology, Klinikum Hanau GmbH, Hanau, Germany
| | - Thomas Müller
- Department of Neurology, St. Joseph Hospital Berlin-Weissensee, Berlin, Germany
| | - Peter Riederer
- Center of Mental Health, Clinic and Policlinic of Psychiatry, Psychosomatics and Psychotherapy, University Hospital, Würzburg, Germany
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Udd M, Lyytinen J, Eerola‐Rautio J, Kenttämies A, Lindström O, Kylänpää L, Pekkonen E. Problems related to levodopa-carbidopa intestinal gel treatment in advanced Parkinson's disease. Brain Behav 2017; 7:e00737. [PMID: 28729942 PMCID: PMC5516610 DOI: 10.1002/brb3.737] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 04/14/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Continuous levodopa-carbidopa intestinal gel (LCIG) diminishes daily "off" time and dyskinesia in patients with advanced Parkinson's disease (PD). Complications are common with percutaneous endoscopic gastrostomy with a jejunal extension tube (PEG-J). AIM OF THE STUDY To report the clinical outcome of LCIG in patients with advanced PD in the years 2006-2014 at Helsinki University Hospital. PATIENTS AND METHODS Levodopa-carbidopa intestinal gel treatment started following PEG-J placement in patients with advanced PD after successful in-hospital LCIG trial with a nasojejunal tube. Demographics, PEG-J procedures, discontinuation of LCIG, complications and mortality were retrospectively analyzed. RESULTS MEAN SD Sixty patients with advanced PD [age 68(7) years; duration of PD: 11(4) years] had LCIG treatment for 26(23) months. The majority of patients with advanced PD were satisfied with the LCIG treatment. For 51 patients (85%), the pump was on for 16 hr a day, and for nine patients (15%) it was on for 24 hr a day. After 6 months, the levodopa-equivalent daily dose (LEDD) had increased by 30% compared to pre-LCIG LEDD. Sixty patients underwent a total of 156 PEG-J procedures, and 48 patients (80%) had a total of 143 complications. Forty-six patients (77%) had 119 PEG-J or peristomal complications, and 22 patients (37%) had a total of 25 other complications. The most common complications were accidental removal of the J-tube in 23 patients (38%) and ≥5% weight loss in 18 patients (30%). Fifteen patients discontinued the LCIG after 21 (21) months. At the end of the follow-up period of 33(27) months, 38 patients were still on LCIG and nine (15%) had died. CONCLUSION Most patients were satisfied with LCIG treatment. A few patients lost weight whereas the majority had complications with PEG-J. When LCIG treatment is carried out, neurological and endoscopic units must be prepared for multiple endoscopic procedures.
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Affiliation(s)
- Marianne Udd
- Department of SurgeryUnit of Therapeutic EndoscopyHelsinki UniversityHelsinkiFinland
| | - Jukka Lyytinen
- Clinical Neurosciences, NeurologyHelsinki UniversityHelsinkiFinland
- Department of NeurologyHelsinki University Hospital and Helsinki UniversityHelsinkiFinland
| | - Johanna Eerola‐Rautio
- Clinical Neurosciences, NeurologyHelsinki UniversityHelsinkiFinland
- Department of NeurologyHelsinki University Hospital and Helsinki UniversityHelsinkiFinland
| | - Anu Kenttämies
- HUS Medical Imaging CenterHelsinki UniversityHelsinkiFinland
| | - Outi Lindström
- Department of SurgeryUnit of Therapeutic EndoscopyHelsinki UniversityHelsinkiFinland
| | - Leena Kylänpää
- Department of SurgeryUnit of Therapeutic EndoscopyHelsinki UniversityHelsinkiFinland
| | - Eero Pekkonen
- Clinical Neurosciences, NeurologyHelsinki UniversityHelsinkiFinland
- Department of NeurologyHelsinki University Hospital and Helsinki UniversityHelsinkiFinland
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Chi J, Ling Y, Jenkins R, Li F. Quantitation of levodopa and carbidopa in rat plasma by LC–MS/MS: The key role of ion-pairing reversed-phase chromatography. J Chromatogr B Analyt Technol Biomed Life Sci 2017; 1054:1-9. [DOI: 10.1016/j.jchromb.2017.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Indexed: 11/28/2022]
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Juhász A, Aschermann Z, Ács P, Janszky J, Kovács M, Makkos A, Harmat M, Tényi D, Karádi K, Komoly S, Takáts A, Tóth A, Nagy H, Klivényi P, Dibó G, Dézsi L, Zádori D, Annus Á, Vécsei L, Varannai L, Kovács N. Levodopa/carbidopa intestinal gel can improve both motor and non-motor experiences of daily living in Parkinson's disease: An open-label study. Parkinsonism Relat Disord 2017; 37:79-86. [PMID: 28185758 DOI: 10.1016/j.parkreldis.2017.02.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 01/09/2017] [Accepted: 02/01/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Levodopa/carbidopa intestinal gel therapy (LCIG) can efficiently improve several motor and non-motor symptoms of advanced Parkinson's disease (PD). The recently developed Movement Disorder Society-sponsored Unified Parkinson's Disease Rating Scale (MDS-UPDRS) improved the original UPDRS making it a more robust tool to evaluate therapeutic changes. However, previous studies have not used the MDS-UPDRS and the Unified Dyskinesia Rating Scale (UDysRS) to assess the efficacy of LCIG. OBJECTIVES Our aim was to determine if the MDS-UPDRS and UDysRS could detect improvement in the experiences of daily living following 1-year LCIG treatment. METHODS In this prospective, multicenter, open-label study, 34 consecutive patients undergoing LCIG treatment were enrolled. Patients were examined twice: prior to LCIG initiation and 12 months later. Impact of PD-related symptoms and dyskinesia was assessed by the MDS-UPDRS and UDysRS. RESULTS Non-motor Experiences of Daily Living part of MDS-UPDRS improved from 20 (median, interquartile-range, IQR:14-23) to 16 points (median, IQR:12-20, p = 0.044) and the Motor Experiences of Daily Living ameliorated from 24 (median, IQR:20-29) to 18 points (median, IQR:13-25, p = 0.025). Health-related quality of life, measured by PDQ-39, also improved from 35.4 (median, IQR:26.9-50.3) to 27.0 (median, IQR:21.3-31.4) points (p = 0.003). The total score of UDysRS decreased from 47 (median, IQR:36-54) to 34 (median, IQR:21-45) points (p = 0.003). CONCLUSIONS As far as the authors are aware of, our paper is the first to evaluate the impact of LCIG on dyskinesia by the means of UDysRS. Changes in MDS-UPDRS and UDysRS confirm that LCIG treatment can efficiently improve experiences of daily living in advanced PD.
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Affiliation(s)
| | | | - Péter Ács
- Department of Neurology, University of Pécs, Pécs, Hungary
| | - József Janszky
- Department of Neurology, University of Pécs, Pécs, Hungary; MTA-PTE Clinical Neuroimaging MR Research Group, Pécs, Hungary
| | - Márton Kovács
- Department of Neurology, University of Pécs, Pécs, Hungary
| | - Attila Makkos
- Department of Neurology, University of Pécs, Pécs, Hungary
| | - Márk Harmat
- Department of Neurology, University of Pécs, Pécs, Hungary
| | - Dalma Tényi
- Department of Neurology, University of Pécs, Pécs, Hungary
| | - Kázmér Karádi
- Institute of Behavioral Sciences, University of Pécs, Pécs, Hungary
| | - Sámuel Komoly
- Department of Neurology, University of Pécs, Pécs, Hungary
| | - Annamária Takáts
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Adrián Tóth
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Helga Nagy
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Péter Klivényi
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - György Dibó
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Lívia Dézsi
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Dénes Zádori
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - Ádám Annus
- Department of Neurology, University of Szeged, Szeged, Hungary
| | - László Vécsei
- Department of Neurology, University of Szeged, Szeged, Hungary; MTA-SZTE Neuroscience Research Group, Szeged, Hungary
| | | | - Norbert Kovács
- Department of Neurology, University of Pécs, Pécs, Hungary; MTA-PTE Clinical Neuroimaging MR Research Group, Pécs, Hungary.
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Timofeeva AA. [Device-aided therapies in advanced Parkinson's disease]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 116:54-60. [PMID: 28139627 DOI: 10.17116/jnevro201611612154-60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Advanced stages of Parkinson's disease (PD) is a consequence of the severe neurodegenerative process and are characterized by the development of motor fluctuations and dyskinesia, aggravation of non-motor symptoms. Treatment with peroral and transdermal drugs can't provide an adequate control of PD symptoms and quality-of-life of the patients at this stage of disease. Currently, three device-aided therapies: deep brain stimulation (DBS), intrajejunal infusion of duodopa, subcutaneous infusion of apomorphine can be used in treatment of patients with advanced stages of PD. Timely administration of device-aided therapies and right choice of the method determine, to a large extent, the efficacy and safety of their use. Despite the high efficacy of all three methods with respect to the fluctuation of separate symptoms, each method has its own peculiarities. The authors reviewed the data on the expediency of using each method according to the severity of motor and non-motor symptoms, patient's age, PD duration, concomitant pathology and social support of the patients.
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Affiliation(s)
- A A Timofeeva
- Pavlov First St. Petersburg State Medical University', St. Petersburg, Россия
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Timpka J, Nitu B, Datieva V, Odin P, Antonini A. Device-Aided Treatment Strategies in Advanced Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 132:453-474. [DOI: 10.1016/bs.irn.2017.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fang JY, Tolleson C. The role of deep brain stimulation in Parkinson's disease: an overview and update on new developments. Neuropsychiatr Dis Treat 2017; 13:723-732. [PMID: 28331322 PMCID: PMC5349504 DOI: 10.2147/ndt.s113998] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Parkinson's disease (PD) is a progressive neurodegenerative disorder characterized by the loss of neuronal dopamine production in the brain. Oral therapies primarily augment the dopaminergic pathway. As the disease progresses, more continuous delivery of therapy is commonly needed. Deep brain stimulation (DBS) has become an effective therapy option for several different neurologic and psychiatric conditions, including PD. It currently has US Food and Drug Administration approval for PD and essential tremor, as well as a humanitarian device exception for dystonia and obsessive-compulsive disorder. For PD treatment, it is currently approved specifically for those patients suffering from complications of pharmacotherapy, including motor fluctuations or dyskinesias, and a disease process of at least 4 years of duration. Studies have demonstrated superiority of DBS and medical management compared to medical management alone in selected PD patients. Optimal patient selection criteria, choice of target, and programming methods for PD and the other indications for DBS are important topics that continue to be explored and remain works in progress. In addition, new hardware options, such as different types of leads, and different software options have recently become available, increasing the potential for greater efficacy and/or reduced side effects. This review gives an overview of therapeutic management in PD, specifically highlighting DBS and some of the recent changes with surgical therapy.
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Affiliation(s)
- John Y Fang
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher Tolleson
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
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Mundt-Petersen U, Odin P. Infusional Therapies, Continuous Dopaminergic Stimulation, and Nonmotor Symptoms. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 134:1019-1044. [DOI: 10.1016/bs.irn.2017.05.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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