Key Considerations in the Use of On-Demand Therapy for Parkinson OFF Episodes: Cheryl Kyinn, PA-C

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"Based off all the clinical data that we have now, the preference is showing that ER (extended-release) formulations are much preferred. All the data suggests that, unfortunately, even though IR (immediate-release) levodopa is great and cheap and effective, long-term use of this volatile pulsing of the medication is going to cause issues over time."

On-demand therapies for Parkinson disease (PD) can offer patients living with the disease a fast and dependable option for managing OFF periods, yet practical guidance on their use has been limited. Research has indicated that motor fluctuations are nearly universal following long-term levodopa therapy, and because the primary treatment goal in PD is to maximize ON time, therapies that act more rapidly than standard oral medications can be highly beneficial. Unlike oral agents for the disease, which are slowed by gastrointestinal absorption issues such as gastroparesis and food interactions, on-demand treatments are designed to bypass the digestive tract altogether.¹

These therapies deliver dopaminergic medication directly into the bloodstream by subcutaneous injection, absorption through the buccal mucosa, or inhalation into the pulmonary circulation. As a result, studies have shown that they achieve onset of action in 10 to 20 minutes and reach reliable, clinically meaningful effects in 30 minutes among patients with PD. By providing swift relief during OFF periods, on-demand options not only can fill critical gap in PD symptom management but also have the potential to significantly improve patients’ daily functioning and overall quality of life.

At the 4th Annual Advanced Therapeutics in Movement and Related Disorders (ATMRD) Congress, held by the PMD Alliance from June 27-30, 2025, movement disorder expert Cheryl Kyinn, PA-C, outlined how on-demand therapies can help manage OFF episodes in PD and shared strategies for their use.² In an interview with NeurologyLive^® at the Congress, Kyinn, a physician assistant specializing in PD in Orange County, California, highlighted studies that reported on the timing and optimal use of these medications. In addition, she stressed the importance of patient education on these on-demand therapies and taken into consideration the preferences of the patient when deciding on which medication to use for treatment.

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REFERENCES
1. Pahwa R, Pagan FL, Kremens DE, Saint-Hilaire M. Clinical Use of On-Demand Therapies for Patients with Parkinson's Disease and OFF Periods. Neurol Ther. 2023;12(4):1033-1049. doi:10.1007/s40120-023-00486-5
2. Kyinn, C. Conquering Off Episodes With On-Demand Therapies. Presented at: ATMRD; June 27-30, 2025; Washington, DC.