Daniel E. Kremens, MD, JD

Panelist discusses how distinguishing between dyskinesia (choreiform, dance-like movements) and tremor in Parkinson disease is crucial for treatment decisions, as modern therapeutic options including extended-release amantadine, continuous subcutaneous delivery systems, and advanced formulations can now effectively manage both motor fluctuations and troublesome dyskinesias simultaneously.

Panelists discuss how distinguishing between dyskinesia (choreoform, dance-like movements) and tremor in Parkinson's disease is crucial for treatment decisions, as modern therapeutic options including extended-release amantadine, continuous subcutaneous delivery systems, and advanced formulations can now effectively manage both motor fluctuations and troublesome dyskinesias simultaneously.

Panelists discuss how treatment decisions for complex cases like the 66-year-old man with severe dyskinesia and 4 hours of daily “off” time require individualized approaches based on patient tolerance, with options including delayed-release/extended-release amantadine (starting at lower doses in older patients due to hallucination risk), extended-release carbidopa-levodopa formulations, infusion pumps for potential deep priming effects, or deep brain stimulation for patients seeking rapid improvement, emphasizing the importance of engaging patients in discussions about their patience for dose adjustments, risk tolerance for adverse effects, and desired timeline for symptom control to guide optimal treatment selection.

Panelists discuss how a 66-year-old man with 8 years of Parkinson disease presenting with severe peak-dose dyskinesia affecting basic functions like eating and speaking, plus 4 hours of daily “off” time despite frequent dosing, represents a patient who should not have been allowed to progress to such advanced motor complications, emphasizing that the preferred approach is early intervention to treat motor fluctuations and dyskinesia as they develop rather than waiting until patients reach this severely impaired state with complex symptoms requiring more intensive management strategies.

Panelists discuss how treatment options for advanced Parkinson disease patients like the 54-year-old woman include deep brain stimulation (DBS) as an excellent choice given her young age and cognitive status, with amantadine delayed-release/extended-release showing robust effects comparable to DBS (about 3 hours of increased good “on” time) in patients meeting DBS criteria, while newer infusion therapies may offer potential benefits through both pharmacokinetic effects from reducing peak-trough levels and a theoretical "deep priming" process that could reset hypersensitive dopamine receptors by providing continuous stimulation, though more research data is needed to confirm these hypothetical benefits.

Panelists discuss how delayed-release/extended-release amantadine represents a unique treatment option for patients like the 54-year-old woman with both dyskinesia and “off” time, as it is the only FDA-approved medication that addresses both conditions simultaneously, with its bedtime dosing and pharmacokinetic profile providing overnight absorption and sustained daytime levels that resulted in phase 3 trials showing a 40% reduction in dyskinesia and 2.4 hours of increased good “on” time, making it an ideal first-line treatment for patients who have both troublesome dyskinesia and motor fluctuations rather than simply reducing dopaminergic medications which would worsen motor symptoms.

Panelists discuss how a 54-year-old woman with early-onset Parkinson disease presenting with troublesome peak-dose dyskinesia affecting her work performance illustrates the challenge of managing patients who have both dyskinesia and likely OFF episodes, requiring careful assessment of functional impacts through targeted questioning about daily activities, work performance, and social interactions, since patients often minimize or remain unaware of their dyskinesia's true impact while caregivers may provide crucial insights into how the involuntary movements affect not only the patient but also family dynamics and professional relationships.

Panelists discuss how dyskinesia affects 30% to 50% of Parkinson patients by 5 years and over 90% by 10 years, creating significant functional limitations including impaired writing, eating, and dressing abilities, increased fall risk, job performance challenges, social isolation due to embarrassment about abnormal movements, and restrictions on therapeutic options since increasing levodopa doses to manage OFF time would worsen dyskinesia, ultimately impacting both patients' basic human dignity and their caregivers' quality of life.

Panelists discuss how newer Parkinson disease therapies may impact dyskinesia management by potentially providing continuous dopaminergic stimulation that could prevent dyskinesia development if used early, though current evidence from phase 3 trials shows mixed results with improvements in good ON time (ON time without troublesome dyskinesia) but limited reduction in existing troublesome dyskinesia, suggesting that while these treatments offer promise, more research is needed to determine their effectiveness in reducing dyskinesia in patients who already experience it.

Panelists discuss how recent advancements in Parkinson disease treatment include 3 newly approved medications—an oral extended-release carbidopa-levodopa with mucoadhesive properties, a subcutaneous foslevodopa infusion, and a subcutaneous apomorphine infusion—that aim to provide more continuous dopamine stimulation and reduce motor fluctuations by offering longer-lasting benefits and smoother symptom control compared with traditional immediate-release formulations.

Panelists discuss how clinical nurse educators serve as vital partners in continuous subcutaneous apomorphine infusion management, providing patient education, troubleshooting technical issues, and collaborating with physicians on dosing titrations to optimize Parkinson disease symptom control.

Panelists discuss how comprehensive education and training resources are essential for clinicians, patients, and caregivers to successfully implement continuous subcutaneous infusion systems in Parkinson disease management.

Panelists discuss how recent approvals of novel delivery systems are reshaping the treatment landscape for Parkinson disease by addressing unmet needs in managing motor fluctuations.

Panelists discuss how their clinical experience with continuous subcutaneous infusion therapies has informed their approach to integrating these treatments into existing regimens, including strategies for medication adjustments and valuable lessons from European clinical practice that could benefit US clinicians.

Panelists discuss how continuous subcutaneous infusion systems should be strategically positioned within Parkinson disease management, typically as options for patients with advanced disease experiencing motor fluctuations despite optimized oral therapy.

Panelists discuss how the newly FDA-approved continuous subcutaneous levodopa infusion system (foscarbidopa/foslevodopa) offers another advanced treatment option, exploring the ideal candidates for these continuous infusion therapies based on disease characteristics, previous treatment responses, and patient preferences.

Panelists discuss how the recently FDA-approved SPN-830 apomorphine infusion pump demonstrated significant efficacy in reducing off time and improving motor function in the INFUS-ON study, with physicians expressing optimistic views about both the US and European clinical trial results.

Panelists discuss how continuous subcutaneous apomorphine infusion (CSAI) demonstrates favorable pharmacokinetics compared with other formulations, with the TOLEDO study and its extension showing significant reductions in off time and improvements in motor function with manageable safety profiles.

Panelists discuss how early recognition of dyskinesia symptoms, ongoing patient-clinician communication, and individualized treatment strategies are key to effectively managing Parkinson disease and improving patients’ quality of life.

Panelists discuss how adjunctive therapies play a crucial role in managing Parkinson disease symptoms, with a particular focus on apomorphine’s unique position in the treatment landscape due to its distinct dopamine receptor binding profile compared with other dopaminergic agents.

Panelists discuss how physicians typically consider advanced Parkinson disease treatments when conventional therapies fail to adequately control motor fluctuations, highlighting challenges such as adverse effects, device-related complications, and patient selection criteria.

Panelists discuss how physicians approach conversations about off time with patients with Parkinson disease, balancing clinical assessment with patient education and shared decision-making.

Panelists discuss how understanding and communication of off episodes for patients with Parkinson disease varies widely in clinical settings, often hindering optimal symptom management.

Panelists discuss how early recognition of dyskinesia symptoms, ongoing patient-clinician communication, and individualized treatment strategies are key to effectively managing Parkinson disease and improving patients’ quality of life.

Panelists discuss how treatment changes in Parkinson disease are necessitated by disease progression, diminishing medication effectiveness, and emerging motor complications, examining a physician’s systematic approach to treatment adjustments and the range of available options for managing off fluctuations.

Panelists discuss how off fluctuations in Parkinson disease become increasingly prevalent as the disease progresses, significantly impacting patient quality of life through reduced mobility, independence, and overall well-being.

Panelists discuss how recent advancements in Parkinson’s disease treatments and a patient-centered approach to care are essential in managing dyskinesia while improving overall symptom control.

Panelists discuss how recent advancements in Parkinson’s disease treatments and a patient-centered approach to care are essential in managing dyskinesia while improving overall symptom control.

An expert discusses D1 receptor agonists that reduce negative symptoms and the increasing availability of recent and upcoming PUMP options for Parkinson disease treatment.

An expert discusses the importance of collaborating with patients, emphasizing the value of leading with data when educating them on the efficacy of treatments, and highlights the role of providers in supporting patients as they discover the medications and supplements that work best for them, while advocating for and protecting patients to ensure they can seek the best quality of life.