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Pharmacokinetics of Levodopa and 3-O-Methyldopa in Parkinsonian Patients Treated with Levodopa and Ropinirole and in Patients with Motor Complications. Pharmaceutics 2021; 13:pharmaceutics13091395. [PMID: 34575471 PMCID: PMC8472364 DOI: 10.3390/pharmaceutics13091395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 01/23/2023] Open
Abstract
Parkinson’s disease (PD) is a progressive, neurodegenerative disorder primarily affecting dopaminergic neuronal systems, with impaired motor function as a consequence. The most effective treatment for PD remains the administration of oral levodopa (LD). Long-term LD treatment is frequently associated with motor fluctuations and dyskinesias, which exert a serious impact on a patient’s quality of life. The aim of our study was to determine the pharmacokinetics of LD: used as monotherapy or in combination with ropinirole, in patients with advanced PD. Furthermore, an effect of ropinirole on the pharmacokinetics of 3-OMD (a major LD metabolite) was assessed. We also investigated the correlation between the pharmacokinetic parameters of LD and 3-OMD and the occurrence of motor complications. Twenty-seven patients with idiopathic PD participated in the study. Thirteen patients received both LD and ropinirole, and fourteen administered LD monotherapy. Among 27 patients, twelve experienced fluctuations and/or dyskinesias, whereas fifteen were free of motor complications. Inter- and intra-individual variation in the LD and 3-OMD concentrations were observed. There were no significant differences in the LD and 3-OMD concentrations between the patients treated with a combined therapy of LD and ropinirole, and LD monotherapy. There were no significant differences in the LD concentrations in patients with and without motor complications; however, plasma 3-OMD levels were significantly higher in patients with motor complications. A linear one-compartment pharmacokinetic model with the first-order absorption was adopted for LD and 3-OMD. Only mean exit (residence) time for 3-OMD was significantly shorter in patients treated with ropinirole. Lag time, V/F, CL/F and tmax of LD had significantly lower values in patients with motor complications. On the other hand, AUC were significantly higher in these patients, both for LD and 3-OMD. 3-OMD Cmax was significantly higher in patients with motor complications as well. Our results showed that ropinirole does not influence LD or 3-OMD concentrations. Higher 3-OMD levels play a role in inducing motor complications during long-term levodopa therapy.
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Weiss D, Volkmann J, Fasano A, Kühn A, Krack P, Deuschl G. Changing Gears - DBS For Dopaminergic Desensitization in Parkinson's Disease? Ann Neurol 2021; 90:699-710. [PMID: 34235776 DOI: 10.1002/ana.26164] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 12/19/2022]
Abstract
In Parkinson's disease, both motor and neuropsychiatric complications unfold as a consequence of both incremental striatal dopaminergic denervation and intensifying long-term dopaminergic treatment. Together, this leads to 'dopaminergic sensitization' steadily increasing motor and behavioral responses to dopaminergic medication that result in the detrimental sequalae of long-term dopaminergic treatment. We review the clinical presentations of 'dopaminergic sensitization', including rebound off and dyskinesia in the motor domain, and neuropsychiatric fluctuations and behavioral addictions with impulse control disorders and dopamine dysregulation syndrome in the neuropsychiatric domain. We summarize state-of-the-art deep brain stimulation, and show that STN-DBS allows dopaminergic medication to be tapered, thus supporting dopaminergic desensitization. In this framework, we develop our integrated debatable viewpoint of "changing gears", that is we suggest rethinking earlier use of subthalamic nucleus deep brain stimulation, when the first clinical signs of dopaminergic motor or neuropsychiatric complications emerge over the steadily progressive disease course. In this sense, subthalamic deep brain stimulation may help reduce longitudinal motor and neuropsychiatric symptom expression - importantly, not by neuroprotection but by supporting dopaminergic desensitization through postoperative medication reduction. Therefore, we suggest considering STN-DBS early enough before patients encounter potentially irreversible psychosocial consequences of dopaminergic complications, but importantly not before a patient shows first clinical signs of dopaminergic complications. We propose to consider neuropsychiatric dopaminergic complications as a new inclusion criterion in addition to established motor criteria, but this concept will require validation in future clinical trials. ANN NEUROL 2021.
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Affiliation(s)
- Daniel Weiss
- Centre for Neurology, Department for Neurodegenerative Diseases, and Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital and Julius-Maximilian-University, Würzburg, Germany
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, ON, Canada.,Division of Neurology, University of Toronto, Toronto, ON, Canada.,Krembil Brain Institute, Toronto, ON, Canada.,Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
| | - Andrea Kühn
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Paul Krack
- Department of Neurology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Günther Deuschl
- Department of Neurology, University Hospital Schleswig Holstein (UKSH), Christian-Albrechts-University Kiel, Kiel, Germany
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Cilia R, Cereda E, Akpalu A, Sarfo FS, Cham M, Laryea R, Obese V, Oppon K, Del Sorbo F, Bonvegna S, Zecchinelli AL, Pezzoli G. Natural history of motor symptoms in Parkinson's disease and the long-duration response to levodopa. Brain 2020; 143:2490-2501. [PMID: 32844196 PMCID: PMC7566883 DOI: 10.1093/brain/awaa181] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/01/2020] [Accepted: 04/14/2020] [Indexed: 01/05/2023] Open
Abstract
The natural pattern of progression of Parkinson’s disease is largely unknown because
patients are conventionally followed on treatment. As Parkinson’s disease progresses, the
true magnitude of the long-duration response to levodopa remains unknown, because it can
only be estimated indirectly in treated patients. We aimed to describe the natural course
of motor symptoms by assessing the natural OFF in consecutive Parkinson’s disease patients
never exposed to treatment (drug-naïve), and to investigate the effects of daily levodopa
on the progression of motor disability in the OFF medication state over a 2-year period.
In this prospective naturalistic study in sub-Saharan Africa, 30 Parkinson’s disease
patients (age at onset 58 ± 14 years, disease duration 7 ± 4 years) began levodopa
monotherapy and were prospectively assessed using the Unified Parkinson’s disease Rating
Scale (UPDRS). Data were collected at baseline, at 1-year and 2-years follow-up.
First-ever levodopa intake induced a significant improvement in motor symptoms (natural
OFF versus ON state UPDRS-III 41.9 ± 15.9 versus 26.8 ± 15.1, respectively;
P < 0.001). At 1-year follow-up, OFF state
UPDRS-III score after overnight withdrawal of levodopa was considerably lower than natural
OFF (26.5 ± 14.9; P < 0 .001). This effect was not
modified by disease duration. At the 2-year follow-up, motor signs after overnight OFF
(30.2 ± 14.2) were still 30% milder than natural OFF
(P = 0.001). The ON state UPDRS-III at the first-ever
levodopa challenge was similar to the overnight OFF score at 1-year follow-up and the two
conditions were correlated (r = 0.72,
P < 0.001). Compared to the natural progression of
motor disability, levodopa treatment resulted in a 31% lower annual decline in UPDRS-III
scores in the OFF state (3.33 versus 2.30 points/year) with a lower model’s variance
explained by disease duration (67% versus 36%). Using the equation regressed on
pretreatment data, we predicted the natural OFF at 1-year and 2-year follow-up visits and
estimated that the magnitude of the long-duration response to levodopa ranged between 60%
and 65% of total motor benefit provided by levodopa, independently of disease duration
(P = 0.13). Although levodopa therapy was associated
with motor fluctuations, overnight OFF disability during levodopa was invariably less
severe than the natural course of the disease, independently of disease duration. The same
applies to the yearly decline in UPDRS-III scores in the OFF state. Further research is
needed to clarify the mechanisms underlying the long-duration response to levodopa in
Parkinson’s disease. Understanding the natural course of Parkinson’s disease and the
long-duration response to levodopa may help to develop therapeutic strategies increasing
its magnitude to improve patient quality of life and to better interpret the outcome of
randomized clinical trials on disease-modifying therapies that still rely on the overnight
OFF to define Parkinson’s disease progression.
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Affiliation(s)
- Roberto Cilia
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Milan, Italy.,Previous address: Parkinson Institute, ASST Gaetano Pini-CTO, Milan, Italy
| | - Emanuele Cereda
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Albert Akpalu
- Korle Bu Teaching Hospital, Accra, Greater Accra region, Ghana
| | | | - Momodou Cham
- Father Novati Catholic Hospital, Sogakope, Volta region, Ghana
| | - Ruth Laryea
- Korle Bu Teaching Hospital, Accra, Greater Accra region, Ghana
| | - Vida Obese
- Komfo Anokye Teaching Hospital, Kumasi, Ashanti region, Ghana
| | - Kenneth Oppon
- Father Novati Catholic Hospital, Sogakope, Volta region, Ghana
| | | | - Salvatore Bonvegna
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Department of Clinical Neurosciences, Parkinson and Movement Disorders Unit, Milan, Italy.,Previous address: Parkinson Institute, ASST Gaetano Pini-CTO, Milan, Italy
| | | | - Gianni Pezzoli
- Parkinson Institute, ASST Gaetano Pini-CTO, Milan, Italy.,Fondazione Grigioni per il Morbo di Parkinson, Milan, Italy
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Screening of Parkinsonian subtle fine-motor impairment from touchscreen typing via deep learning. Sci Rep 2020; 10:12623. [PMID: 32724210 PMCID: PMC7387517 DOI: 10.1038/s41598-020-69369-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/30/2020] [Indexed: 11/22/2022] Open
Abstract
Fine-motor impairment (FMI) is progressively expressed in early Parkinson’s Disease (PD) patients and is now known to be evident in the immediate prodromal stage of the condition. The clinical techniques for detecting FMI may not be robust enough and here, we show that the subtle FMI of early PD patients can be effectively estimated from the analysis of natural smartphone touchscreen typing via deep learning networks, trained in stages of initialization and fine-tuning. In a validation dataset of 36,000 typing sessions from 39 subjects (17 healthy/22 PD patients with medically validated UPDRS Part III single-item scores), the proposed approach achieved values of area under the receiver operating characteristic curve (AUC) of 0.89 (95% confidence interval: 0.80–0.96) with sensitivity/specificity: 0.90/0.83. The derived estimations result in statistically significant (\documentclass[12pt]{minimal}
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\begin{document}$$p<0.05$$\end{document}p<0.05) correlation of 0.66/0.73/0.58 with the clinical standard UPDRS Part III items 22/23/31, respectively. Further validation analysis on 9 de novo PD patients vs. 17 healthy controls classification resulted in AUC of 0.97 (0.93–1.00) with 0.93/0.90. For 253 remote study participants, with self-reported health status providing 252.000 typing sessions via a touchscreen typing data acquisition mobile app (iPrognosis), the proposed approach predicted 0.79 AUC (0.66–0.91) with 0.76/0.71. Remote and unobtrusive screening of subtle FMI via natural smartphone usage, may assist in consolidating early and accurate diagnosis of PD.
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Effects of daily L-dopa administration on learning and brain structure in older adults undergoing cognitive training: a randomised clinical trial. Sci Rep 2020; 10:5227. [PMID: 32251360 PMCID: PMC7090037 DOI: 10.1038/s41598-020-62172-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 03/04/2020] [Indexed: 11/08/2022] Open
Abstract
Cognitive aging creates major individual and societal burden, motivating search for treatment and preventive care strategies. Behavioural interventions can improve cognitive performance in older age, but effects are small. Basic research has implicated dopaminergic signalling in plasticity. We investigated whether supplementation with the dopamine-precursor L-dopa improves effects of cognitive training on performance. Sixty-three participants for this randomised, parallel-group, double-blind, placebo-controlled trial were recruited via newspaper advertisements. Inclusion criteria were: age of 65–75 years, Mini-Mental State Examination score >25, absence of serious medical conditions. Eligible subjects were randomly allocated to either receive 100/25 mg L-dopa/benserazide (n = 32) or placebo (n = 31) prior to each of twenty cognitive training sessions administered during a four-week period. Participants and staff were blinded to group assignment. Primary outcomes were latent variables of spatial and verbal fluid intelligence. Compared to the placebo group, subjects receiving L-dopa improved less in spatial intelligence (−0.267 SDs; 95%CI [−0.498, −0.036]; p = 0.024). Change in verbal intelligence did not significantly differ between the groups (−0.081 SDs, 95%CI [−0.242, 0.080]; p = 0.323). Subjects receiving L-dopa also progressed slower through the training and the groups displayed differential volumetric changes in the midbrain. No statistically significant differences were found for the secondary cognitive outcomes. Adverse events occurred for 10 (31%) and 7 (23%) participants in the active and control groups, correspondingly. The results speak against early pharmacological interventions in older healthy adults to improve broader cognitive functions by targeting the dopaminergic system and provide no support for learning-enhancing properties of L-dopa supplements in the healthy elderly. The findings warrant closer investigation about the cognitive effects of early dopamine-replacement therapy in neurological disorders. This trial was preregistered at the European Clinical Trial Registry, EudraCT#2016-000891-54 (2016-10-05).
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Teixeira FG, Vilaça-Faria H, Domingues AV, Campos J, Salgado AJ. Preclinical Comparison of Stem Cells Secretome and Levodopa Application in a 6-Hydroxydopamine Rat Model of Parkinson's Disease. Cells 2020; 9:cells9020315. [PMID: 32012897 PMCID: PMC7072263 DOI: 10.3390/cells9020315] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/22/2020] [Accepted: 01/22/2020] [Indexed: 12/18/2022] Open
Abstract
Parkinson's Disease (PD) is characterized by the massive loss of dopaminergic neurons, leading to the appearance of several motor impairments. Current pharmacological treatments, such as the use of levodopa, are yet unable to cure the disease. Therefore, there is a need for novel strategies, particularly those that can combine in an integrated manner neuroprotection and neuroregeneration properties. In vitro and in vivo models have recently revealed that the secretome of mesenchymal stem cells (MSCs) holds a promising potential for treating PD, given its effects on neural survival, proliferation, differentiation. In the present study, we aimed to access the impact of human bone marrow MSCs (hBM-MSCs) secretome in 6-hydroxydopamine (6-OHDA) PD model when compared to levodopa administration, by addressing animals' motor performance, and substantia nigra (SN), and striatum (STR) histological parameters by tyrosine hydroxylase (TH) expression. Results revealed that hBM-MSCs secretome per se appears to be a modulator of the dopaminergic system, enhancing TH-positive cells expression (e.g., dopaminergic neurons) and terminals both in the SN and STR when compared to the untreated group 6-OHDA. Such finding was positively correlated with a significant amelioration of the motor outcomes of 6-OHDA PD animals (assessed by the staircase test). Thus, the present findings support hBM-MSCs secretome administration as a potential therapeutic tool in treating PD, and although we suggest candidate molecules (Trx1, SEMA7A, UCHL1, PEDF, BDNF, Clusterin, SDF-1, CypA, CypB, Cys C, VEGF, DJ-1, Gal-1, GDNF, CDH2, IL-6, HSP27, PRDX1, UBE3A, MMP-2, and GDN) and possible mechanisms of hBM-MSCs secretome-mediated effects, further detailed studies are needed to carefully and clearly define which players may be responsible for its therapeutic actions. By doing so, it will be reasonable to presume that potential treatments that can, per se, or in combination modulate or slow PD may lead to a rational design of new therapeutic or adjuvant strategies for its functional modeling and repair.
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Affiliation(s)
- Fábio G. Teixeira
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal; (H.V.-F.); (J.C.)
- ICVS/3B’s Associate Lab, PT Government Associated Lab, 4806-909 Braga/Guimarães, Portugal
- Correspondence: (F.G.T.); (A.J.S.); Tel.: +351-253-60-48-71 (F.G.T.); +351-253-60-49-47 (A.J.S.)
| | - Helena Vilaça-Faria
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal; (H.V.-F.); (J.C.)
- ICVS/3B’s Associate Lab, PT Government Associated Lab, 4806-909 Braga/Guimarães, Portugal
| | - Ana V. Domingues
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal; (H.V.-F.); (J.C.)
- ICVS/3B’s Associate Lab, PT Government Associated Lab, 4806-909 Braga/Guimarães, Portugal
| | - Jonas Campos
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal; (H.V.-F.); (J.C.)
- ICVS/3B’s Associate Lab, PT Government Associated Lab, 4806-909 Braga/Guimarães, Portugal
| | - António J. Salgado
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, 4710-057 Braga, Portugal; (H.V.-F.); (J.C.)
- ICVS/3B’s Associate Lab, PT Government Associated Lab, 4806-909 Braga/Guimarães, Portugal
- Correspondence: (F.G.T.); (A.J.S.); Tel.: +351-253-60-48-71 (F.G.T.); +351-253-60-49-47 (A.J.S.)
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Kim H, Mason S, Foltynie T, Winder‐Rhodes S, Barker RA, Williams‐Gray CH. Motor complications in Parkinson's disease: 13-year follow-up of the CamPaIGN cohort. Mov Disord 2020; 35:185-190. [PMID: 31965629 PMCID: PMC7063985 DOI: 10.1002/mds.27882] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/12/2019] [Accepted: 09/09/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Long-term population-representative data on motor fluctuations and levodopa-induced dyskinesias in Parkinson's disease is lacking. METHODS The Cambridgeshire Parkinson's Incidence from GP to Neurologist (CamPaIGN) cohort comprises incident PD cases followed for up to 13 years (n = 141). Cumulative incidence of motor fluctuations and levodopa-induced dyskinesias and risk factors were assessed using Kaplan-Meyer and Cox regression analyses. RESULTS Cumulative incidence of motor fluctuations and levodopa-induced dyskinesias was 54.3% and 14.5%, respectively, at 5 years and 100% and 55.7%, respectively, at 10 years. Higher baseline UPDRS-total and SNCA rs356219(A) predicted motor fluctuations, whereas higher baseline Mini-mental State Examination and GBA mutations predicted levodopa-induced dyskinesias. Early levodopa use did not predict motor complications. Both early motor fluctuations and levodopa-induced dyskinesias predicted reduced mortality in older patients (age at diagnosis >70 years). CONCLUSIONS Our data support the hypothesis that motor complications are related to the severity of nigrostriatal pathology rather than early levodopa use and indicate that early motor complications do not necessarily confer a negative prognosis. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Han‐Joon Kim
- Department of Neurology and Movement Disorder CenterCollege of Medicine, Seoul National UniversitySeoulKorea
| | - Sarah Mason
- John van Geest Centre for Brain Repair, Department of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
| | - Thomas Foltynie
- Department of Clinical & Movement NeurosciencesUCL Queen Square Institute of NeurologyLondonUK
| | - Sophie Winder‐Rhodes
- John van Geest Centre for Brain Repair, Department of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
| | - Roger A. Barker
- John van Geest Centre for Brain Repair, Department of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
| | - Caroline H. Williams‐Gray
- John van Geest Centre for Brain Repair, Department of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
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Cabreira V, Soares-da-Silva P, Massano J. Contemporary Options for the Management of Motor Complications in Parkinson's Disease: Updated Clinical Review. Drugs 2019; 79:593-608. [PMID: 30905034 DOI: 10.1007/s40265-019-01098-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Parkinson's disease (PD) is a chronic, progressive condition affecting around 1% of the population older than 60 years. Upon long-term treatment with levodopa, the mainstay of treatment in PD, most patients, especially younger ones exposed to higher doses, will experience symptoms related to end-of-dose deterioration, peak-dose dyskinesias, and other motor fluctuations. Therapeutic strategies are grounded on modification of oral levodopa pharmacokinetics to extend levodopa benefit and development of new routes of drug delivery (e.g., levodopa/carbidopa intestinal gel infusion) or long-acting formulations of existing dopaminergic drugs to prolong the duration of striatal dopamine receptors stimulation. As our understanding of the pathophysiology of motor complications evolves, our therapeutic armamentarium is actively expanding and the focus of research is now actively pointing to the new non-dopaminergic agents acting both within the basal ganglia and in other brain regions (e.g., drugs acting on glutamate, GABA, serotonin, and calcium channels). Despite the fact that trials comparing the different therapeutic strategies are lacking, we aimed at devising practical evidence- and experience-guided suggestions for the clinical management of motor complications, emphasizing that this should always be an individualized endeavor. This review summarizes the pharmacological management of motor complications in PD, including new formulations and routes of delivery, and the newer released drugs such as istradefylline, opicapone, safinamide, and zonisamide. Advanced therapeutic strategies for selected cases such as treatment with apomorphine and surgical techniques (deep brain stimulation) are also discussed. A comprehensive knowledge of the available options and evidence is fundamental for the successful management of these challenging complications.
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Affiliation(s)
- Verónica Cabreira
- Department of Neurology, Centro Hospitalar Universitário de S. João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Patrício Soares-da-Silva
- Department of Biomedicine, Pharmacology and Therapeutics Unit, Faculty of Medicine, University of Porto, Porto, Portugal.,MedInUP, Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal.,Department of Research and Development, BIAL, Portela & Cª S.A., S. Mamede do Coronado, Portugal
| | - João Massano
- Department of Neurology, Centro Hospitalar Universitário de S. João, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal. .,Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal.
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Safinamide in Clinical Practice: A Spanish Multicenter Cohort Study. Brain Sci 2019; 9:brainsci9100272. [PMID: 31614574 PMCID: PMC6826846 DOI: 10.3390/brainsci9100272] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/29/2019] [Accepted: 10/09/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Safinamide is an approved drug for the treatment of motor fluctuations of Parkinson's Disease (PD) patients with a potential benefit on non-motor symptoms (NMS). Methods: A retrospective multicenter cohort study was conducted, in which the clinical effect of safinamide on both motor and NMS was assessed by the Clinical Global Impression of Change scale. Furthermore, we assessed the appearance of adverse events (AEs) and its effect on dyskinesia, that were also recorded in non-fluctuating PD patients and in those previously treated with rasagiline. Results: We included 213 PD patients who received safinamide in addition to their regular levodopa therapy. Thirty-five withdrew prematurely from safinamide, mainly because of AEs. Out of 178, clinical improvement on motor and NMS was found in 76.4% and 26.2%, respectively. A total of 44 reported AEs of mild intensity. We did not find a difference concerning the clinical benefit or AEs when comparing either patients who had or had not been taking Monoamine Oxidase B Inhibitor (MAOB-I) previously or between patients with and without motor complications. Conclusions: Safinamide is an effective and safe add-on to levodopa drug for PD patients. Moreover, safinamide could elicit an additional clinical improvement in PD patients previously treated with other MAOB-I and in non- fluctuating patients with suboptimal motor control.
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Mehanna R, Jankovic J. Young-onset Parkinson's disease: Its unique features and their impact on quality of life. Parkinsonism Relat Disord 2019; 65:39-48. [DOI: 10.1016/j.parkreldis.2019.06.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/29/2019] [Accepted: 06/01/2019] [Indexed: 12/23/2022]
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12
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Dyskinesias and levodopa therapy: why wait? J Neural Transm (Vienna) 2018; 125:1119-1130. [PMID: 29428995 DOI: 10.1007/s00702-018-1856-6] [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] [Accepted: 02/05/2018] [Indexed: 12/28/2022]
Abstract
Throughout the years there has been a longstanding discussion on whether levodopa therapy in Parkinson's disease should be started in early vs. later stages, in order to prevent or delay motor complications such as fluctuations and dyskinesias. This controversial topic has been extensively debated for decades, and the prevailing view today is that levodopa should not be postponed. However, there is still fear associated with its use in early stages, especially in younger patients, who are more prone to develop dyskinesias. Even though dyskinesias are linked to levodopa use in Parkinson's disease, it has been shown that starting with a different medication (such as dopamine agonists) will not significantly delay their onset once levodopa is introduced. Since levodopa provides better symptomatic control, and other drugs may be associated with notable side effects, it is our view that there is insufficient evidence to justify levodopa-sparing strategies. The physician should try to assess each patient individually, taking into account motor and non-motor demands, as well as risk factors for potential complications, finding the optimum treatment strategy for each one. The following article provides an historical narrative perspective, as well as a literature review of those intrinsic and modifiable risk factors that have been associated with levodopa-induced dyskinesias, which should be taken into consideration when choosing the therapeutic strategy in individual Parkinson's disease patients.
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Cereda E, Cilia R, Canesi M, Tesei S, Mariani CB, Zecchinelli AL, Pezzoli G. Efficacy of rasagiline and selegiline in Parkinson's disease: a head-to-head 3-year retrospective case-control study. J Neurol 2017; 264:1254-1263. [PMID: 28550482 PMCID: PMC5570795 DOI: 10.1007/s00415-017-8523-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/16/2017] [Accepted: 05/17/2017] [Indexed: 12/21/2022]
Abstract
Monoamine oxidase type B (MAO-B) inhibitors, such as selegiline and rasagiline, can be used as monotherapy or adjuvant therapy to levodopa in Parkinson’s disease (PD). Data on long-term efficacy of MAO-B inhibitors are limited with no head-to-head comparison available to date. The aim of this case–control retrospective study was to analyze data from patients with PD attending the Parkinson Institute (Milan, Italy) over a 6-year period (2009–2015) and compare the effects of selegiline and rasagiline on levodopa treatment outcomes. Patients with PD treated with either selegiline (n = 85) or rasagiline (n = 85) for 3 years as well as a control group of patients (N = 170) who have never received MAO-B inhibitors, were matched for gender, disease duration (±1 year) and age (±1 year) at baseline assessment (ratio 1:1:2). The Unified PD Rating Scale and the Hoehn–Yahr staging system were used for clinical comparisons. At baseline, mean PD duration was 6.5 years and clinical features were comparable across all three groups. After a mean follow-up of approximately 37 months, no differences in clinical progression of motor and non-motor symptoms were observed between the three groups. However, MAO-B inhibitor use was associated with ~2-fold lower change in daily dose of levodopa (p < 0.001) and lower dyskinesia scores (p = 0.028) than non-users. No intra-class differences were observed between selegiline and rasagiline. Long-term use of MAO-B inhibitors resulted in a significant reduction in levodopa requirements and a lower frequency of dyskinesias in patients with PD. Selegiline and rasagiline had equal efficacy in controlling motor symptoms in PD patients on optimized therapy.
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Affiliation(s)
- Emanuele Cereda
- Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100, Pavia, Italy.
| | - Roberto Cilia
- Parkinson Institute, ASST G. Pini-CTO, ex-ICP, Milan, Italy
| | | | - Silvana Tesei
- Parkinson Institute, ASST G. Pini-CTO, ex-ICP, Milan, Italy
| | | | | | - Gianni Pezzoli
- Parkinson Institute, ASST G. Pini-CTO, ex-ICP, Milan, Italy
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Lancioni G, Singh N, O'Reilly M, Sigafoos J, D'Amico F, Sasanelli G, Denitto F, Lang R. Technology-aided leisure and communication: Opportunities for persons with advanced Parkinson's disease. Dev Neurorehabil 2016; 19:398-404. [PMID: 25826719 DOI: 10.3109/17518423.2014.1002637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE This study investigated whether simple technology-aided programs could be used to promote leisure and communication engagement in three persons with advanced Parkinson's disease. METHOD The programs included music and video options, which were combined with (a) text messaging and telephone calls for the first participant, (b) verbal statements/requests, text messaging, and reading for the second participant, and (c) verbal statements/requests and prayers for the third participant. The participants could activate those options via hand movement or vocal emission and specific microswitches. RESULTS All three participants were successful in activating the options available. The mean cumulative frequencies of option activations were about five per 15-min session for the first two participants and about four per 10-min session for the third participant. CONCLUSION The results were considered encouraging and relevant given the limited amount of evidence available on helping persons with advanced Parkinson's disease with leisure and communication.
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Affiliation(s)
- Giulio Lancioni
- a Department of Neuroscience and Sense Organs , University of Bari , Bari , Italy
| | - Nirbhay Singh
- b Medical College of Georgia, Georgia Regents University , Augusta , GA , USA
| | - Mark O'Reilly
- c Department of Special Education , University of Texas at Austin , Austin , TX , USA
| | - Jeff Sigafoos
- d Department of Educational Psychology , Victoria University of Wellington , Wellington , New Zealand
| | - Fiora D'Amico
- e S. Raffaele Medical Care Center , Alberobello , Italy
| | | | | | - Russell Lang
- g Department of Curriculum Instruction , Texas State University , San Marcos , TX , USA
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Huot P, Fox SH, Brotchie JM. Dopamine Reuptake Inhibitors in Parkinson's Disease: A Review of Nonhuman Primate Studies and Clinical Trials. J Pharmacol Exp Ther 2016; 357:562-9. [PMID: 27190169 DOI: 10.1124/jpet.116.232371] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/06/2016] [Indexed: 01/22/2023] Open
Abstract
Striatal dopamine deficiency is the core feature of the pathology of Parkinson's disease (PD), and dopamine replacement with l-3,4-dihydroxyphenylalanine (l-DOPA) is the mainstay of PD treatment. Unfortunately, chronic l-DOPA administration is marred by the emergence of dyskinesia and wearing-off. Alternatives to l-DOPA for alleviation of parkinsonism are of interest, although none can match the efficacy of l-DOPA to date. Catechol-O-methyltransferase and monoamine oxidase inhibitors are currently used to alleviate wearing-off, but they do not increase "on-time" without exacerbating dyskinesia. Alternate approaches to dopamine replacement in parkinsonism generally (and to wearing-off and dyskinesia, specifically) are therefore urgently needed. Inasmuch as they increase synaptic dopamine levels, dopamine transporter (DAT) inhibitors, whether they are selective or have actions on noradrenaline or serotonin transporters, theoretically represent an attractive way to alleviate parkinsonism per se and potentially enhance l-DOPA antiparkinsonian action (provided that sufficient dopamine terminals remain within the striatum). Several nonhuman primate studies and clinical trials have been performed to evaluate the potential of DAT inhibitors for PD. In this article, we review nonhuman primate studies and clinical trials, we summarize the current knowledge of DAT inhibitors in PD, and we propose a hypothesis as to how tailoring the selectivity of DAT inhibitors might maximize the benefits of DAT inhibition in PD.
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Bjornestad A, Forsaa EB, Pedersen KF, Tysnes OB, Larsen JP, Alves G. Risk and course of motor complications in a population-based incident Parkinson's disease cohort. Parkinsonism Relat Disord 2015; 22:48-53. [PMID: 26585090 DOI: 10.1016/j.parkreldis.2015.11.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/09/2015] [Accepted: 11/02/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Motor complications may become major challenges in the management of patients with Parkinson's disease. In this study, we sought to determine the incidence, risk factors, evolution, and treatment of motor fluctuations and dyskinesias in a population-representative, incident Parkinson's disease cohort. METHODS In this prospective population-based 5-year longitudinal study, we followed 189 incident and initially drug-naïve Parkinson's disease patients biannually for detailed examination of dyskinesias and motor fluctuations as defined by the Unified Parkinson's disease Rating Scale. We performed Kaplan-Meier survival and Cox regression analyses to assess cumulative incidence and risk factors of these motor complications. RESULTS The 5-year cumulative incidence of motor complications was 52.4%. Motor fluctuations occurred in 42.9% and dyskinesias in 24.3%. Besides higher motor severity predicting both motor fluctuations (p = 0.016) and dyskinesias (p < 0.001), lower age at diagnosis predicted motor fluctuations (p = 0.001), whereas female gender predicted dyskinesias (p = 0.001). Actual levodopa dose at onset of motor fluctuations (p = 0.037) or dyskinesias (p < 0.001) rather than initial treatment with levodopa (p > 0.1) independently predicted development of motor complications. Motor fluctuations reversed in 37% and dyskinesias in 49% of patients on oral treatment and remained generally mild in those with persistent complications. No patients received device-aided therapies during the study. CONCLUSIONS More than 50% in the general Parkinson's disease population develop motor complications within 5 years of diagnosis. However, they remain mild in the vast majority and are reversible in a substantial proportion of patients.
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Affiliation(s)
- Anders Bjornestad
- The Norwegian Centre for Movement Disorders, Stavanger University Hospital, PO Box 8100, N-4068 Stavanger, Norway; Department of Neurology, Stavanger University Hospital, Stavanger, Norway.
| | - Elin B Forsaa
- The Norwegian Centre for Movement Disorders, Stavanger University Hospital, PO Box 8100, N-4068 Stavanger, Norway; Department of Neurology, Stavanger University Hospital, Stavanger, Norway.
| | - Kenn Freddy Pedersen
- The Norwegian Centre for Movement Disorders, Stavanger University Hospital, PO Box 8100, N-4068 Stavanger, Norway; Department of Neurology, Stavanger University Hospital, Stavanger, Norway.
| | - Ole-Bjorn Tysnes
- Department of Neurology, Haukeland University Hospital, PO Box 1400, N-5021 Bergen, Norway; Institute of Clinical Medicine, University of Bergen, Norway.
| | - Jan Petter Larsen
- The Norwegian Centre for Movement Disorders, Stavanger University Hospital, PO Box 8100, N-4068 Stavanger, Norway.
| | - Guido Alves
- The Norwegian Centre for Movement Disorders, Stavanger University Hospital, PO Box 8100, N-4068 Stavanger, Norway; Department of Neurology, Stavanger University Hospital, Stavanger, Norway.
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Jenner P. Treatment of the later stages of Parkinson's disease - pharmacological approaches now and in the future. Transl Neurodegener 2015; 4:3. [PMID: 25973178 PMCID: PMC4429454 DOI: 10.1186/2047-9158-4-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/01/2015] [Indexed: 11/10/2022] Open
Abstract
The problems associated with the pharmacological treatment of the later stages of Parkinson's disease (PD) remain those seen over many years. These centre on a loss of drug effect ('wearing off') with disease progression, the occurrence of dyskinesia, notably with L-dopa use and the appearance of non-motor symptoms that are largely refractory to dopaminergic medication. Treatment strategies in late PD have been dominated by the use of drug combinations and the subtle manipulation of drug dosage. However, change is occurring as the understanding of the basis of motor complications and fluctuations and non-motor symptoms improves. New pharmacological options are expanding with the advent of longer acting versions of existing dopaminergic drugs, new drug delivery systems and the introduction of non-dopaminergic agents able to manipulate motor function both within the basal ganglia and in other brain regions. Non-dopaminergic agents are also being investigated for the treatment of dyskinesia and for the relief of non-motor symptoms. However, while therapy continues to improve, the treatment of late stage PD remains problematic with non-motor symptoms dominating the unmet need in this patient group.
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Affiliation(s)
- Peter Jenner
- Neurodegenerative Diseases Research Group, Institute of Pharmaceutical Sciences, Faculty of Health Sciences and Medicine, King's College, London, SE1 1UL UK
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