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Livingston C, Monroe-Duprey L. A Review of Levodopa Formulations for the Treatment of Parkinson's Disease Available in the United States. J Pharm Pract 2024; 37:485-494. [PMID: 36704966 DOI: 10.1177/08971900221151194] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Purpose: The safety and efficacy of levodopa formulations are evaluated to inform clinical decision making for the treatment of Parkinson's disease. Summary: Levodopa is a cornerstone of treatment for Parkinson's disease due to its proven efficacy. Although many patients can initially be managed using immediate release tablets, as their disease progresses they often require escalating doses as well as more frequent dosing to prevent wearing off effects. Additionally, patients who experience time in the off state may struggle with the delay between medication administration and onset of action. Therefore, to increase patient convenience as well as to enhance the pharmacokinetic profile of the levodopa, several other formulations have been developed. Levodopa coformulated with carbidopa is supplied as immediate release tablets, oral disintegrating tablets, controlled release tablets, extended release capsules, and a continuous enteral solution. Additionally, there is a levodopa inhalation powder available. As a result of their different absorption profiles, each formulation has unique safety and efficacy attributes. Consequently, while this expansion of levodopa formulations has substantially increased treatment options for patients, it has also increased the complexity of medical decision making for patients, providers, and health systems alike. Conclusion: Knowledge of the different pharmacokinetic, safety and efficacy profiles of the available levodopa formulations is critical for the effective management of Parkinson's disease on both the individual patient and population levels.
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Affiliation(s)
- Clare Livingston
- Department of Pharmacy, Inova Health System, Alexandria, VA, USA
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2
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Arav Y, Zohar A. Model-based optimization of controlled release formulation of levodopa for Parkinson's disease. Sci Rep 2023; 13:15869. [PMID: 37739971 PMCID: PMC10517026 DOI: 10.1038/s41598-023-42878-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023] Open
Abstract
Levodopa is currently the standard of care treatment for Parkinson's disease, but chronic therapy has been linked to motor complications. Designing a controlled release formulation (CRF) that maintains sustained and constant blood concentrations may reduce these complications. Still, it is challenging due to levodopa's pharmacokinetic properties and the notion that it is absorbed only in the upper small intestine (i.e., exhibits an "absorption window"). We created and validated a physiologically based mathematical model to aid the development of such a formulation. Analysis of experimental results using the model revealed that levodopa is well absorbed throughout the entire small intestine (i.e., no "absorption window") and that levodopa in the stomach causes fluctuations during the first 3 h after administration. Based on these insights, we developed guidelines for an improved CRF for various stages of Parkinson's disease. Such a formulation is expected to produce steady concentrations and prolong therapeutic duration compared to a common CRF with a smaller dose per day and a lower overall dose of levodopa, thereby improving patient compliance with the dosage regime.
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Affiliation(s)
- Yehuda Arav
- Department of Applied Mathematics, Israeli Institute for Biological Research, PO Box 19, 7410001, Ness-Ziona, Israel.
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Tarianyk KA, Lytvynenko NV, Purdenko TY, Sylenko H. Y HY. OPTIMIZATION THE TREATMENT OF MOTOR FLUCTUATIONS VARIOUS FORMS OF PARKINSON’S DISEASE. BULLETIN OF PROBLEMS BIOLOGY AND MEDICINE 2022. [DOI: 10.29254/2077-4214-2022-3-166-262-266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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4
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Lyu Y, Huang Y, Shi G, Lei X, Li K, Zhou R, Bai L, Qin C. Transcriptome profiling of five brain regions in a 6-hydroxydopamine rat model of Parkinson's disease. CNS Neurosci Ther 2021; 27:1289-1299. [PMID: 34347369 PMCID: PMC8504527 DOI: 10.1111/cns.13702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Parkinson's disease (PD) is a neurodegenerative disease, and its pathogenesis is unclear. Previous studies mainly focus on the lesions of substantia nigra (SN) and striatum (Str) in PD. However, lesions are not limited. The olfactory bulb (OB), subventricular zone (SVZ), and hippocampus (Hippo) are also affected in PD. AIM To reveal gene expression changes in the five brain regions (OB, SVZ, Str, SN, and Hippo), and to look for potential candidate genes and pathways that may be correlated with the pathogenesis of PD. MATERIALS AND METHODS We established control group and 6-hydroxydopamine (6-OHDA) PD model group, and detected gene expressions in the five brain regions using RNA-seq and real-time quantitative polymerase chain reaction (RT-qPCR). We further analyzed the RNA-seq data by bioinformatics. RESULTS We identified differentially expressed genes (DEGs) in all five brain regions. The DEGs were significantly enriched in the "dopaminergic synapse" and "retrograde endocannabinoid signaling," and Gi/o-GIRK is the shared cascade in the two pathways. We further identified Ephx2, Fam111a, and Gng2 as the potential candidate genes in the pathogenesis of PD for further studies. CONCLUSION Our study suggested that gene expressions change in the five brain regions following exposure to 6-OHDA. The "dopaminergic synapse," "retrograde endocannabinoid signaling," and Gi/o-GIRK may be the key pathways and cascade of the synaptic damage in 6-OHDA PD rats. Ephx2, Fam111a, and Gng2 may play critical roles in the pathogenesis of PD.
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Affiliation(s)
- Ying Lyu
- Institute of Laboratory Animal Sciences (ILAS), Chinese Academy of Medical Sciences (CAMS) & Comparative Medical Center, Peking Union Medical College (PUMC), Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China.,Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yiying Huang
- Institute of Laboratory Animal Sciences (ILAS), Chinese Academy of Medical Sciences (CAMS) & Comparative Medical Center, Peking Union Medical College (PUMC), Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China
| | - Guiying Shi
- Institute of Laboratory Animal Sciences (ILAS), Chinese Academy of Medical Sciences (CAMS) & Comparative Medical Center, Peking Union Medical College (PUMC), Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China
| | - Xuepei Lei
- Institute of Laboratory Animal Sciences (ILAS), Chinese Academy of Medical Sciences (CAMS) & Comparative Medical Center, Peking Union Medical College (PUMC), Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China
| | - Keya Li
- Institute of Laboratory Animal Sciences (ILAS), Chinese Academy of Medical Sciences (CAMS) & Comparative Medical Center, Peking Union Medical College (PUMC), Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China
| | - Ran Zhou
- Beijing City University, Beijing, China
| | - Lin Bai
- Institute of Laboratory Animal Sciences (ILAS), Chinese Academy of Medical Sciences (CAMS) & Comparative Medical Center, Peking Union Medical College (PUMC), Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China
| | - Chuan Qin
- Institute of Laboratory Animal Sciences (ILAS), Chinese Academy of Medical Sciences (CAMS) & Comparative Medical Center, Peking Union Medical College (PUMC), Beijing, China.,Beijing Engineering Research Center for Experimental Animal Models of Human Critical Diseases, Beijing, China
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5
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Tan SJ, Ismail IS. Potency of Selected Berries, Grapes, and Citrus Fruit as Neuroprotective Agents. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2020; 2020:3582947. [PMID: 32565853 PMCID: PMC7277024 DOI: 10.1155/2020/3582947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022]
Abstract
A healthy diet should nourish the brain with essential nutrients, including bioactive compounds, for normal brain functioning and to protect it from the negative effects of inflammation and oxidative stress. In this review, a concise summation of the protective effects of selected fruits, namely, berries, grapes, and citrus fruits, against neurological disorder is presented. The focus is on the neuroprotective potential of these fruits against neurodegenerative and mental disorders. The fruits selection was based on the vast reported pharmacological studies on their neuroprotection efficacies. Hence, the respective knowledge and limitations are discussed based on the biological and pharmacological evidence compiled from the previously reported laboratory, epidemiology, and intervention trials.
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Affiliation(s)
- Shih Jen Tan
- Laboratory of Natural Products, Institute of Bioscience, Universiti Putra Malaysia, 43000 Serdang, Selangor, Malaysia
| | - Intan Safinar Ismail
- Laboratory of Natural Products, Institute of Bioscience, Universiti Putra Malaysia, 43000 Serdang, Selangor, Malaysia
- Department of Chemistry, Faculty of Science, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
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6
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Briggs RG, Ahsan SA, Conner AK, Nix CE, Jacobs CC, Jones RG, Sheets JR, Palejwala AH, Chendeb K, Sughrue ME. Neurochemical supplementation in patients with depressed levels of participation after brain tumor surgery: Rationale and preliminary results. J Clin Neurosci 2019; 71:93-96. [PMID: 31771803 DOI: 10.1016/j.jocn.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 09/04/2019] [Accepted: 10/04/2019] [Indexed: 11/16/2022]
Abstract
A unique challenge in some brain tumor patients is the fact that tumors arising in certain areas of the brain involve the neural structures of consciousness or alertness, limiting the patient's ability to participate in rehabilitation following surgery. A critical question is whether neurostimulant therapy can help patients participate in rehabilitation efforts. We performed a retrospective review of all patients undergoing brain tumor surgery by the senior author from 2012 to 2018. We limited this study to patients with tumors occupying critical structures related to consciousness, alertness, and motor initiation. A combination of methylphenidate and levodopa/carbidopa was used to monitor the progress of patients through neurorehabilitation efforts. We identified 101 patients who experienced an inability to participate in rehabilitation (ITPR) in the post-operative period. Of these, 86 patients (85%) were treated with methylphenidate and levodopa/carbidopa. Cases of ITPR were related to dysfunction of the brainstem (12/86 cases, 14%), thalamus (17/86 cases, 20%), hypothalamus (14/86 cases, 16%), basal ganglia (13/86 cases, 15%), and medial frontal lobe (30/86 cases, 35%). Of the 86 individuals treated, 47/86 patients (55%) showed early improvement in their ability to participate with rehabilitation. At three month follow-up, 58/86 patients (67%) had returned to living independently or were at least interactive and cooperative during follow-up examination. This feasibility report suggests that combined therapy with methylphenidate and levodopa/carbidopa may help patients participate in neurorehabilitation efforts in the immediate post-operative period following brain tumor surgery. Randomized, controlled clinical trials are needed to explore this concept more thoroughly.
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Affiliation(s)
- Robert G Briggs
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, Australia
| | - Syed A Ahsan
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, Australia
| | - Cameron E Nix
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, Australia
| | - Christina C Jacobs
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, Australia
| | - Ryan G Jones
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, Australia
| | - John R Sheets
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, Australia
| | - Ali H Palejwala
- Department of Neurosurgery, University of Oklahoma Health Science Center, Oklahoma City, OK, Australia
| | - Kassem Chendeb
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Michael E Sughrue
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.
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7
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Lin MM, Laureno R. Less Pulsatile Levodopa Therapy (6 Doses Daily) Is Associated with a Reduced Incidence of Dyskinesia. J Mov Disord 2019; 12:37-42. [PMID: 30732431 PMCID: PMC6369375 DOI: 10.14802/jmd.18046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 12/12/2018] [Indexed: 11/30/2022] Open
Abstract
Objective To evaluate whether less pulsatile levodopa therapy (LPT) can reduce the development of levodopa-induced dyskinesia (LID). Methods This is a retrospective cohort study of patients with Parkinson’s disease at the movement disorders clinic of Medstar Washington Hospital Center. The study was not blinded or randomized. Patients were seen between August 2002 and August 2018. During these years, we treated patients with less pulsatile (6 doses daily) levodopa treatment to reduce LID. Occurrence of LID was recorded. Results Ninety-five patients with Parkinson’s disease taking levodopa were divided into two groups: 1) patients who were initially managed on LPT or who switched from traditional therapy (TT) (n = 61) (mean disease duration: 7.7 ± 4.8 years, mean levodopa duration: 5.6 ± 4.5 years and mean observation time: 4.3 ± 3.4 years), and 2) patients on TT throughout the observation period or until they developed dyskinesia (n = 34) (mean disease duration: 8.3 ± 3.8 years, mean levodopa duration: 6.2 ± 4.2 years and mean observation time: 4.1 ± 3.4 years). Three of the 61 LPT patients developed dyskinesia during the observation period. One of the patients developed dyskinesia after being switched to pulsatile doses by another doctor. In the other two, dyskinesia was minimal. In contrast to this 4.9% cumulative incidence, dyskinesia occurred in 50% (17/34) of TT patients, an incidence similar to that in published data (p < 0.001). Conclusion Less pulsatile levodopa with 6 daily doses was associated with a low incidence of LID. Further study of this method of treatment is warranted.
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Affiliation(s)
- Mark M Lin
- Department of Neurology, Medstar Washington Hospital Center, Medstar Georgetown University Hospital and Georgetown University School of Medicine, Washington, DC, USA
| | - Robert Laureno
- Department of Neurology, Medstar Washington Hospital Center, Medstar Georgetown University Hospital and Georgetown University School of Medicine, Washington, DC, USA
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8
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Müller T, Möhr JD. Efficacy of carbidopa-levodopa extended-release capsules (IPX066) in the treatment of Parkinson Disease. Expert Opin Pharmacother 2018; 19:2063-2071. [DOI: 10.1080/14656566.2018.1538355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Thomas Müller
- Department of Neurology, St. Joseph Hospital Berlin-Weißensee , Berlin, Germany
| | - Jan-Dominique Möhr
- Department of Neurology, St. Joseph Hospital Berlin-Weißensee , Berlin, Germany
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9
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Abstract
Parkinson's disease (PD) is a chronic progressive neurological disorder characterized by resting tremor, rigidity, bradykinesia, gait disturbance, and postural instability. Levodopa, the precursor to dopamine, coadministered with carbidopa or benserazide, aromatic amino acid decarboxylase inhibitors, is the most effective and widely used therapeutic agent in the treatment of PD. With continued levodopa treatment, a majority of patients develop motor complications such as dyskinesia and motor 'on-off' fluctuations, which are, in part, related to the fluctuations in plasma concentrations of levodopa. A new extended-release (ER) carbidopa-levodopa capsule product (also referred to as IPX066) was developed and approved in the US as Rytary® and in the EU as Numient®. The capsule formulation is designed to provide an initial rapid absorption of levodopa comparable to immediate-release (IR) carbidopa-levodopa, and to subsequently provide stable levodopa concentrations with reduced peak-to-trough excursions in plasma concentrations in order to reduce motor fluctuations associated with pulsatile stimulation of dopamine receptors and to minimize dyskinesia. Phase III studies of this ER carbidopa-levodopa capsule formulation in patients with PD have shown a significant reduction in 'off' time compared with IR carbidopa-levodopa and carbidopa-levodopa-entacapone. We present a review of the clinical pharmacokinetics and pharmacodynamics of this ER product of carbidopa-levodopa in healthy subjects and in patients with PD.
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10
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Baek JS, Tee JK, Pang YY, Tan EY, Lim KL, Ho HK, Loo SCJ. Improved Bioavailability of Levodopa Using Floatable Spray-Coated Microcapsules for the Management of Parkinson's Disease. Neuromolecular Med 2018; 20:262-270. [PMID: 29696585 DOI: 10.1007/s12017-018-8491-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/23/2018] [Indexed: 12/14/2022]
Abstract
Oral administration of levodopa (LD) is the gold standard in managing Parkinson's disease (PD). Although LD is the most effective drug in treating PD, chronic administration of LD induces levodopa-induced dyskinesia. A continuous and sustained provision of LD to the brain could, therefore, reduce peak-dose dyskinesia. In commercial oral formulations, LD is co-administrated with an AADC inhibitor (carbidopa) and a COMT inhibitor (entacapone) to enhance its bioavailability. Nevertheless, patients are known to take up to five tablets a day because of poor sustained-releasing capabilities that lead to fluctuations in plasma concentrations. To achieve a prolonged release of LD with the aim of improving its bioavailability, floatable spray-coated microcapsules containing all three PD drugs were developed. This gastro-retentive delivery system showed sustained release of all PD drugs, at similar release kinetics. Pharmacokinetics study was conducted and this newly developed formulation showed a more plateaued delivery of LD that is void of the plasma concentration fluctuations observed for the control (commercial formulation). At the same time, measurements of LD and dopamine of mice administered with this formulation showed enhanced bioavailability of LD. This study highlights a floatable, sustained-releasing delivery system in achieving improved pharmacokinetics data compared to a commercial formulation.
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Affiliation(s)
- Jong-Suep Baek
- School of Materials Science and Engineering, Nanyang Technological University, 50 Nanyang Avenue, Singapore, 639798, Singapore
| | - Jie Kai Tee
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Yi Yun Pang
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Ern Yu Tan
- General Surgery Clinic, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Kah Leong Lim
- National Neuroscience Institute (NNI), 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Han Kiat Ho
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, Singapore, 117543, Singapore
| | - Say Chye Joachim Loo
- School of Materials Science and Engineering, Nanyang Technological University, 50 Nanyang Avenue, Singapore, 639798, Singapore. .,Singapore Centre on Environmental Life Sciences Engineering (SCELSE), Nanyang Technological University, Singapore, 637551, Singapore.
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11
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Hauser RA, Ellenbogen A, Khanna S, Gupta S, Modi NB. Onset and duration of effect of extended-release carbidopa-levodopa in advanced Parkinson's disease. Neuropsychiatr Dis Treat 2018; 14:839-845. [PMID: 29606877 PMCID: PMC5868609 DOI: 10.2147/ndt.s153321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In patients with Parkinson's disease (PD), oral dosing of extended-release carbidopa-levodopa (Rytary, IPX066 [ER CD-LD]) achieves peak levodopa plasma concentrations within 1 hour and maintains them for 4-6 hours. AIMS To compare the onset and duration of ER CD-LD benefit with those of immediate-release carbidopa-levodopa (IR CD-LD) in PD patients with motor fluctuations, using crossover data, and to evaluate which threshold values of improvement in finger-tapping and Unified Parkinson's Disease Rating Scale (UPDRS) motor scores yield results most similar to those for trained raters' "on"/"off" assessments. METHODS Patients underwent serial "on"/"off" rating and provided serial finger-tapping and UPDRS motor scores after receiving, in an "off" state, their usual morning IR dose or an ER dose designed to produce a similar levodopa peak concentration. Predefined improvement thresholds for analysis were 10%, 15%, and 20% increases in finger-tapping score and 2.5, 5, 7, and 11-point decreases in UPDRS motor score. Serial plasma samples were assayed for levodopa. RESULTS Among 27 patients, mean time to onset of an "on" state was similar for ER compared with IR CD-LD (0.83 vs 0.81 hour), but mean duration was significantly longer for ER CD-LD than for IR CD-LD (5.56 vs 2.69 hours; P<0.0001). Duration was best matched by a $20% improvement in finger-tapping, a $11-point improvement in UPDRS motor score, and a levodopa plasma concentration $1,000 ng/mL. CONCLUSION For ER CD-LD, observer assessments of "on" state were corroborated by sustained treatment effects. Correlations among "on"-state duration, finger-tapping score, and UPDRS motor score may suggest clinically relevant thresholds for acute assessment of treatment benefit.
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Affiliation(s)
- Robert A Hauser
- Departments of Neurology, Molecular Pharmacology, and Physiology, University of South Florida, Tampa, FL, USA
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12
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Tambasco N, Romoli M, Calabresi P. Levodopa in Parkinson's Disease: Current Status and Future Developments. Curr Neuropharmacol 2018; 16:1239-1252. [PMID: 28494719 PMCID: PMC6187751 DOI: 10.2174/1570159x15666170510143821] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 04/25/2017] [Accepted: 05/09/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Ever since the pioneering reports in the 60s, L-3,4-Dioxyphenylalanine (levodopa) has represented the gold standard for the treatment of Parkinson's Disease (PD). However, long-term levodopa (LD) treatment is frequently associated with fluctuations in motor response with serious impact on patient quality of life. The pharmacokinetic and pharmacodynamic properties of LD are pivotal to such motor fluctuations: discontinuous drug delivery, short half-life, poor bioavailability, and narrow therapeutic window are all crucial for such fluctuations. During the last 60 years, several attempts have been made to improve LD treatment and avoid long-term complications. METHODS Research and trials to improve the LD pharmacokinetic since 1960s are reviewed, summarizing the progressive improvements of LD treatment. RESULTS Inhibitors of peripheral amino acid decarboxylase (AADC) have been introduced to achieve proper LD concentration in the central nervous system reducing systemic adverse events. Inhibitors of catechol-O-methyltransferase (COMT) increased LD half-life and bioavailability. Efforts are still being made to achieve a continuous dopaminergic stimulation, with the combination of oral LD with an AADC inhibitor and a COMT inhibitor, or the intra-duodenal water-based LD/ carbidopa gel. Further approaches to enhance LD efficacy are focused on new non-oral administration routes, including nasal, intra-duodenal, intrapulmonary (CVT-301) and subcutaneous (ND0612), as well as on novel ER formulations, including IPX066, which recently concluded phase III trial. CONCLUSION New LD formulations, oral compounds as well as routes have been tested in the last years, with two main targets: achieve continuous dopaminergic stimulation and find an instant deliver route for LD.
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Affiliation(s)
- Nicola Tambasco
- Address correspondence to this author at the Clinica Neurologica, Azienda Ospedaliera e Universitaria di Perugia, Loc. S.Andrea delle Fratte 06156, Perugia, Italy; Tel: +39-075-5783830; Fax: +39-075-5784229;, E-mail:
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13
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Margolesky J, Singer C. Extended-release oral capsule of carbidopa-levodopa in Parkinson disease. Ther Adv Neurol Disord 2017; 11:1756285617737728. [PMID: 29399046 PMCID: PMC5784558 DOI: 10.1177/1756285617737728] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 09/25/2017] [Indexed: 11/17/2022] Open
Abstract
Motor fluctuations complicate the treatment of patients with Parkinson's disease receiving levodopa. Extended-release carbidopa-levodopa has a pharmacokinetic profile that provides a more continuous levodopa serum concentration. Patients taking this formulation can expect longer duration of action and fewer doses per day, similar clinical improvement when compared to other levodopa formulations, and with a theoretically lower risk of developing motor fluctuations. Several studies, including three randomized control trials provide evidence for the efficacy, safety and tolerability of extended release carbidopa-levodopa in patients with both early and advanced Parkinson's disease are reviewed here. Also provided is guidance for dosing of and conversion to extended release carbidopa-levodopa as well as a discussion of its place in the clinical practice.
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Affiliation(s)
| | - Carlos Singer
- University of Miami School of Medicine, 1150 NW 14th St, Suite 609, Miami, FL 33136-1015, USA
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14
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Sintov AC, Levy HV, Greenberg I. Continuous Transdermal Delivery of L-DOPA Based on a Self-Assembling Nanomicellar System. Pharm Res 2017; 34:1459-1468. [DOI: 10.1007/s11095-017-2162-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 04/05/2017] [Indexed: 11/25/2022]
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15
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Abstract
This article summarizes (1) the recent achievements to further improve symptomatic therapy of motor Parkinson’s disease (PD) symptoms, (2) the still-few attempts to systematically search for symptomatic therapy of non-motor symptoms in PD, and (3) the advances in the development and clinical testing of compounds which promise to offer disease modification in already-manifest PD. However, prevention (that is, slowing or stopping PD in a prodromal stage) is still a dream and one reason for this is that we have no consensus on primary endpoints for clinical trials which reflect the progression in prodromal stages of PD, such as in rapid eye movement sleep behavior disorder (RBD) —a methodological challenge to be met in the future.
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Affiliation(s)
- Wolfgang H Oertel
- Department of Neurology, University Clinic, Philipps Universität Marburg, Marburg, Germany; Institute for Neurogenomics, Helmholtz Center for Health and Environment, Munich, Germany
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16
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Marsili L, Marconi R, Colosimo C. Treatment Strategies in Early Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 132:345-360. [PMID: 28554414 DOI: 10.1016/bs.irn.2017.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
The clinicians' approach to the treatment of early Parkinson's disease (PD) should take into account numerous aspects, including how to inform a patient upon diagnosis and the critical decision of what therapy to adopt and when to start it. The treatment of the motor disorder associated with early PD needs to consider several crucial factors, such as age at onset, comorbidities, and the patient's functional requirements, and cannot be summarized in a simple formula. In younger patients (i.e., before the age of 70) and in those without high functional requirements, treatment is usually initiated with dopamine agonists and/or monoamine oxidase-B enzyme inhibitors (MAO-B I). By contrast, in older patients, or in those with high functional requirements, low doses of levodopa are generally used when treatment is started. In younger patients, levodopa should be added to dopamine agonists and/or MAO-B I, as required by disease progression, whereas in older patients, when response to levodopa alone is not satisfactory, dopamine agonists or catechol-O-methyltransferase inhibitors may subsequently be added.
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Affiliation(s)
- Luca Marsili
- Sapienza University of Rome, Rome, Italy; Misericordia Hospital, Grosseto, Italy
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17
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Abstract
PURPOSE OF REVIEW We aim to review the most interesting recent advances on the clinical aspects of continuous dopaminergic stimulation in Parkinson's disease. RECENT FINDINGS Several large, open-label studies have presented data that are in line with the randomized controlled trial on L-dopa-carbidopa intestinal gel infusion, which shows that a continuous drug delivery can improve motor fluctuations and dyskinesia in patients with advanced Parkinson's disease. Furthermore, new extended-release formulations of L-dopa aim to stabilize plasma concentrations and thus reduce the degree of motor complications - despite a reduced number of daily doses. Transdermal rotigotine has been shown to be effective for specific subgroups of patients, although the general effect on nonmotor symptoms is still unclear. New products for L-dopa infusion are also at different stages of development, but the routes of administration are widely different: intrajejunal, subcutaneous, and oral. SUMMARY The understanding of the mechanisms behind the complications of long-term L-dopa treatment is still not complete, but therapies aiming for continuous dopaminergic stimulation are already widely used in clinical practice and the evidence strength is improving. However, there is still an urgent need for both less invasive and less costly options in order to increase access to these therapies.
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Abstract
Levodopa remains the most effective treatment for Parkinson's disease and is considered the gold standard therapy. However, disease progression and changes in the gastrointestinal tract result in a declining window of treatment response in a majority of patients. Efforts have been made recently to improve levodopa bioavailability either by developing more effective oral formulations or by innovating routes of administration (intestinal infusion, transcutaneous or inhaled levodopa). IPX066 is a novel levodopa-carbidopa (LD/CD) oral formulation combining immediate-release (IR) and extended-release (ER) LD/CD recently approved in the USA and the EU. Levodopa-carbidopa intestinal gel (LCIG) is an approved therapy consisting of a suspension of levodopa and carbidopa infused directly into the proximal jejunum via a percutaneous endoscopic gastrojejunostomy (PEG-J) tube through a portable infusion pump. Ongoing studies are evaluating the 'accordion pill' (AP09004), an ER LD/CD formulation with gastroretentive properties. ND0612 is a proprietary liquid formulation of LD/CD that enables subcutaneous administration via a small patch-pump device, and CVT-301 is a levodopa inhalation powder with rapid onset of action; both are currently in active studies. Other novel formulations have been discontinued, including DM-1992, which is a bilayer formulation containing an IR LD/CD layer and an ER LD/CD layer with gastroretentive properties, and XP21279, a novel oral levodopa prodrug that is absorbed from the small and large intestine by high-capacity nutrient transporters expressed throughout the gastrointestinal system. ODM-101 is a new oral formulation of levodopa/carbidopa/entacapone that contains a higher amount of carbidopa (65 or 105 mg), but no active studies are underway. The current review aims to summarize the pharmacokinetic aspects, clinical efficacy, and potential adverse events of novel levodopa formulations currently available or under development.
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Nausieda PA, Hsu A, Elmer L, Gil RA, Spiegel J, Singer C, Khanna S, Rubens R, Kell S, Modi NB, Gupta S. Conversion to IPX066 from Standard Levodopa Formulations in Advanced Parkinson's Disease: Experience in Clinical Trials. JOURNAL OF PARKINSONS DISEASE 2016; 5:837-45. [PMID: 26444090 PMCID: PMC4927929 DOI: 10.3233/jpd-150622] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Due to the short half-life of levodopa, immediate-release carbidopa-levodopa (IR CD-LD) produces fluctuating LD concentrations, contributing to a risk of eventual motor complications. IPX066 was designed to rapidly attain therapeutic LD concentrations and maintain them to allow a dosing interval of ∼6 hours. Objective: To extensively analyze the dosing data collected in IPX066 studies during open-label conversions from IR CD-LD alone or with entacapone (CLE) and identify patterns relevant for managing conversion in the clinical setting. Methods: Patients had ≥2.5 hours/day of “off” time despite a stable IR or CLE regimen. Suggested initial dosing conversion tables based on prior LD daily dosage were provided. Results: Of 450 patients previously treated with IR CD-LD and 110 with CLE, 87.3% and 82.7% completed conversion to IPX066, respectively. At the end of conversion, average IPX066 LD daily dosages were higher than pre-conversion dosages, with a mean conversion ratio of 2.1±0.6 for IR CD-LD and 2.8±0.8 for CLE; >90% of patients took IPX066 3 or 4 times/day, compared with a median of 5 times/day at baseline in both studies. After conversion, daily “off” time significantly decreased, with no significant increase in troublesome dyskinesia. The most common adverse event reported during conversion was nausea, with an incidence of 5.3% for conversion from IR and 7.3% from CLE. Conclusions: Among PD patients with substantial “off” time, a majority were safely converted to IPX066. The sustained LD profile from the IPX066 formulation allowed an increase in LD dose accompanied by improved motor functions, without increased troublesome dyskinesia.
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Affiliation(s)
- Paul A Nausieda
- Wisconsin Institute for Neurologic and Sleep Disorders, Milwaukee, WI, USA
| | - Ann Hsu
- Impax Laboratories, Inc., Hayward, CA, USA
| | - Lawrence Elmer
- University of Toledo College of Medicine, Toledo, OH, USA
| | - Ramon A Gil
- Charlotte Neurological Services, Port Charlotte, FL, USA
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Silver DE, Trosch RM. Physicians' experience with RYTARY (carbidopa and levodopa) extended-release capsules in patients who have Parkinson disease. Neurology 2016; 86:S25-35. [PMID: 27044647 DOI: 10.1212/wnl.0000000000002511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A discussion between Dr. Dee Silver and Dr. Richard Trosch provides insight and advice for physicians considering a switch from immediate-release carbidopa-levodopa (IR CD-LD) to RYTARY as a treatment for patients with Parkinson disease (PD). The dialogue describes how they identify patients with PD who may and may not be successful switching to RYTARY, how they approach the conversion process and patient compliance, and how they address some side effects that may occur after patients begin taking RYTARY. The clinicians also discuss their experiences with how long it takes to establish a stable regimen as well as provide general advice regarding conversion from treatment with IR CD-LD to RYTARY.
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Affiliation(s)
- Dee E Silver
- From the Coastal Neurological Medical Group, Inc. (D.E.S.), La Jolla, CA; and the Parkinson's and Movement Disorders Center (R.M.T.), Farmington Hills, MI
| | - Richard M Trosch
- From the Coastal Neurological Medical Group, Inc. (D.E.S.), La Jolla, CA; and the Parkinson's and Movement Disorders Center (R.M.T.), Farmington Hills, MI.
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22
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Kianirad Y, Simuni T. Novel Approaches to Optimization of Levodopa Therapy for Parkinson’s Disease. Curr Neurol Neurosci Rep 2016; 16:34. [DOI: 10.1007/s11910-016-0635-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
INTRODUCTION Parkinson's disease (PD) is one of the most challenging neurodegenerative disorders to treat as it manifests with a large variety of troublesome, and often disabling, motor and non-motor symptoms. Despite limitations, such as motor and other complications, levodopa remains the most effective drug in the treatment of PD. AREAS COVERED In this review, we focus on phase 2 and 3 studies describing new and emerging medical therapies in PD. We discuss new formulations of levodopa, medications that prolong levodopa response and ameliorate levodopa-induced dyskinesias, and innovative delivery methods that are currently being evaluated in clinical trials or are in development with the promise of better efficacy and tolerability. We also describe novel non-dopaminergic drugs that have been identified for treatment of motor and non-motor symptoms. A specific section is designated for potential disease modifying therapies. EXPERT OPINION Alternative formulations of levodopa appear to be promising especially to help with the motor fluctuations either by providing sustained benefits with controlled released formulations or ameliorate sudden OFF by formulations such as inhaled levodopa. Several different medications affecting non-dopaminergic pathways are being evaluated which may aide levodopa. As the understanding of the disease grows further, numerous novel neuroprotective or disease modifying therapies have been suggested. This along with development of medications to treat various non-motor symptoms will help improve quality of life of patients with PD.
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Affiliation(s)
- Mitesh Lotia
- a Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology , Baylor College of Medicine , Houston , TX , USA
| | - Joseph Jankovic
- a Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology , Baylor College of Medicine , Houston , TX , USA
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Abstract
A new extended-release (ER) capsule formulation of carbidopa/levodopa (Rytary(®), Numient™, IPX066) is available for the treatment of Parkinson's disease (PD). Carbidopa/levodopa ER capsules contain beads of carbidopa and levodopa, designed to release the drugs at different rates in the gastrointestinal tract and provide constant therapeutic levodopa concentrations that are maintained for 4-5 h (after an initial peak at ≈ 1 h). In randomized phase III trials, oral carbidopa/levodopa ER was significantly more effective than placebo with regard to improving motor symptoms and activities of daily living in patients with early PD after 30 weeks' treatment, and provided significantly greater reductions in daily 'off-time' in patients with advanced PD than immediate-release (IR) carbidopa/levodopa or carbidopa/levodopa IR plus entacapone after a treatment period of 13 and 2 weeks, respectively, without increasing troublesome dyskinesia. The efficacy of carbidopa/levodopa ER was maintained during a 9-month open-label extension in patients with early or advanced PD. Carbidopa/levodopa ER was generally well tolerated in clinical trials, with the most common adverse events in the extension study being nausea and insomnia in patients with early PD and falls and dyskinesia in patients with advanced PD. Thus, carbidopa/levodopa ER is an effective and generally well-tolerated treatment option for the motor symptoms of PD, reducing periods of 'off-time' compared with carbidopa/levodopa IR without increasing troublesome dyskinesia.
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