Current Series: Managing OFF Episodes in Parkinson Disease

Stuart Isaacson, MD: You know, it brings up the other problem. We talked about all of the phone calls, and the emails, and notes in how we handle all that time and data. But Jill, you have a busy practice. How do you incorporate infusional therapies, and on-demand therapies, and educate patients about all of these during a visit?

Jill M. Giordano Farmer, DO, MPH: One of the nice things about the on-demand therapies that are available now, especially with the apomorphine subcutaneous infusion, is they have ancillary support that’s able to help the doctor and the patient. One of the reasons typically why this hadn’t caught on in the past was they thought that it had to be initiated in the office and that there needed to be a lot of time with taking the care to educate the patient on how to do the injection. And what did neurologists know about teaching a patient how to do the injection?

So they have a support system of nurses who are able to do the infusions in the patient’s home. They’re able to take first pass at calls when they come in about questions that come with doing the injection, and they’re able to teach the patient and the caregiver how to do the injection. That really takes the onus off the doctor to have to spend a lot of time in their own practice during the day to be able to do this. Same is for the infusion therapies, for the jejunal levodopa. They also have nurses who are able to go out to the house to educate the patient about how to care for the device, do the flushing, things like that. So while you will still get questions, and questions will come through, you are not the first pass for those types of therapies, which makes it much more user friendly.

Stuart Isaacson, MD: And online, there are also videos that can help patients learn how to use these injections, use the inhaled levodopa, and it’s been helpful to have some of these resources.

Peter LeWitt, MD, M.Med.Sc: It’s also worth pointing out that if one doesn’t want to have a proxy of someone to do it and wants to keep it within the office practice, these are compensated activities. They’re not charitable endeavors. Patients coming into your office and getting titrated to effect is something that is part of good medical practice, and it is paid for by Medicare and other sources of income. But I think it also gives patients confidence to have these kinds of support services of expert people in their own home and in real life settings, and having that kind of access that isn’t a burden to the physician, certainly incentivizes those of us who think office practice is the total part of our work obligation.

Rajesh Pahwa, MD: One of the challenges we have faced with subcutaneous apomorphine as on-demand therapy is the acceptance, both from the patient and the physician. When we have the subcutaneous apomorphine infusion available, are we going to have the same concerns with the patient saying, “Oh, it’s a pump. I have to carry it around. Can I go swimming? Can I take a shower with it?” Are these concerns that we can address with them? Are these concerns that some patients are going to go away from? What happens when this patient ends up in assisted living? How are they going to take care of the pump? So, those challenges….

Peter LeWitt, MD, M.Med.Sc: Well, we have diabetes therapy that’s going in that direction, especially in young, active people who are using subcutaneous pumps. In fact, the therapies that we’re going to use for Parkinson disease have been taken from the infusion world of insulin and other medications. I think we’re going to have to change the mindset of physicians who, in neurology, are also using infusion therapies for multiple sclerosis and perhaps other inflammatory diseases.

Rajesh Pahwa, MD: But the difference is this is a pump. They have to have it...it’s like a 1-time deal for an hour.

Peter LeWitt, MD, M.Med.Sc: But the idea is the prescription pad is not just for pills anymore, and physicians have to be open to delivery systems, including training patients properly on how to use inhaled levodopa powder, which is somewhat of an art, having been involved in the clinical trials. I think also, the fact that caregivers are part of the education package. That’s one of the nice things that these home services offer. They look upon the home setting and going beyond the patient, especially with injecting apomorphine. It often requires the spouse or caregiver to be a part of that process.

Stuart Isaacson, MD: Raj, you’ve opened up this door about access. Patients have to have access to new therapies so they can decide whether they want to try them, and to benefit from them. So it requires awareness and education of prescribers, and patients, and their families to understand and destigmatize these therapies. And it involves educating formularies.

Daniel E. Kremens, MD, JD: I think this is really crucial to understanding that just throwing another dose of levodopa at the patient is generally not going to solve the problem, most of the time. People really have to be open to the fact that there are new therapies beyond just another pill. That other pill, much of the time, may be helpful; but a lot of the time, particularly in our more advanced patients, it’s not going to be. And that’s where the notion of rational polypharmacy, bringing in non-dopaminergic therapies, bringing in on-demand therapies to really optimize the experience for the patient….

Rajesh Pahwa, MD: But the thing is, for us as neurologists, we have not had pumps that we have had patients use. I think we have to make sure we spend enough time teaching the patients, the physicians the advantages of this therapy and how to use it correctly, because it’s a first subcutaneous therapy on a continuous infusion that’s going to be available. If it is not used correctly, it is not going to have the benefits that we know we can provide our patients with. And whether that is from patient selection or how the therapy is given, or what doses is given…. Now remember, in general neurologists often under dose their patients. And again, if you use an infusion therapy and you under dose it and it doesn’t work, well, it’s not that the therapy is not working. The patient is not the getting adequate amount of that medication.

Daniel E. Kremens, MD, JD: Sure. But again, this is a therapy that has been used in Europe for many years. It’s a therapy that I think once people are exposed to it, will realize that this is not difficult to use. You draw the analogy of the insulin pump that’s revolutionized the treatment of diabetes. I think we potentially have the opportunity to truly improve things for our Parkinson patients as these therapies become available.

Jill M. Giordano Farmer, DO, MPH: I think one of the ways to make it more palatable is that, especially for the subcutaneous levodopa infusion that is being looked into, it’s the same drug that they have orally. So if there is any concern that they will be under dosed, or that it will fail, or that it won’t be utilized, they have the resource of just taking their oral medication, although it might not be ideal if they’re looking for a different delivery. Anyway, in the short course, if there’s an issue or a concern, they have that as a backup option.

Rajesh Pahwa, MD: Right. But what I was talking about is with the apomorphine subcutaneous infusion, which is going to be out before we have the levodopa infusion, the thing is to get the adequate benefit from the apomorphine infusion part. We don’t want people to just be started on a low-dose apomorphine infusion and not get the benefits. We know you need 5, 6 mg an hour to get those.

Stuart Isaacson, MD: With apomorphine, you have to find that right dose.

Rajesh Pahwa, MD: Correct.

Stuart Isaacson, MD: It works like levodopa. It’s the only thing that works like levodopa.