Current Series: Case Based Insights: Parkinson

Fernando L. Pagan, MD: We have a case here, and it’s a 63-year-old female who was diagnosed with Parkinson’s disease about 4 years ago. She is currently working as a third-grade teacher. Her medications are a carbidopa 25 mg and levodopa 100 mg 4 times a day, with rasagiline 1 mg in the morning. She takes the medicines about every 4 to 5 hours. She was started on carbidopa-levodopa approximately 4 years ago. At this current office visit, she mentioned that she has noticed that there are periods where she sees that her tremor is reemerging. Some days she has excellent control and other days that she doesn’t. She also states that there are tough periods throughout the day when she feels like the medicine has worn off a little, and she has increased tremor, which makes it difficult to get through the rest of her day. There is no particular pattern to it. Some days she’s been really good about taking her medications at the appropriate intervals, and other days, even if she’s very good at taking her medications, she feels these medicines wearing off. 
 
One of the things that could be done is using the levodopa inhalation powder, and that was one of the things that was worked on in this particular clinic visit. 
 
One of the things you look at when you see this particular patient is this: this is a person who has had Parkinson’s disease for 4 years. For people with Parkinson’s disease at the 4-year mark, you see wearing off or off episodes about 25% of the time. The longer you’ve been with Parkinson’s disease, the more likely you’re going to experience more off time. The rationale in approaching these patients is to potentially increase the overall dose of the carbidopa-levodopa. You can increase the frequency or the overall dosage to increase the strength because she’s only on 1 tablet. 
 
The other thing you can do is add adjunctive medications. She’s already on a MAO-B inhibitor, but you could consider, considering her age, a dopamine agonist. You can also consider a COMT inhibitor. There are medications that can definitely be added on, and now we have a new class of medicines: the A2aR antagonist that can also be used to give more on time. 
 
Regardless of what you do, everything you do probably increases or decreases on and off time, respectively, about 1 to 2 hours each way, and patients still have off time and off periods. There has been a shift in the paradigm. Just like in headache, we have medications to prevent the headaches, but then we also have medicines to abort the headaches, so it is beneficial to give a maintenance dose and decrease the overall off time and have more on time. There are going to be unpredictable periods where having an on-demand therapy makes a lot of sense. I think we’re seeing this change in paradigm in movement disorders.