Parkinson’s Disease On-Demand Morning Therapy - Episode 10
Neurologists debate the use of levodopa inhalation powder in managing Parkinson’s disease.
Stuart Isaacson, MD: We have a lot of these new on-demand therapies that are not absorbed through the GI [gastrointestinal] system that have become available. We have the levodopa inhalation powder. We have the sublingual apomorphine strip film. We also continue to have the injection subcutaneously of apomorphine that’s been available for 15 years. Let’s talk a little bit more about these therapies and see if we can understand maybe which ones we might choose here, or there, or what patient scenarios. Khash, do you want to tell us a little bit about your understanding and experiences with the levodopa inhalation powder, how it works, how it’s delivered, its mechanism of action and any advantages or disadvantages when you think about prescribing this drug?
Khashayar Dashtipor, MD: When I introduce my patients to this on-demand therapy, I go through the pros and cons of each one, such as inhaler levodopa. One big advantage is that it’s levodopa. We know that levodopa is one of the most potent medications and is the safest medication because of the adverse effect profile. That applies to when we use an inhaler as well.
One of the distinct adverse effects about inhaler levodopa comes from the mode of delivery of that. Coughing is one of its adverse effects. In comparison to other on-demand therapies, the rest of the adverse effects are definitely minimal, which is a big advantage.
There is some caution that you have to exercise when you use it with a patient with COPD [chronic obstructive pulmonary disease] or asthma. As we know, those type of patients were excluded from the clinical trial. There are some post hoc analyses that showed that even patients with asthma use that. But we know that it can cause bronchospasm. I try to avoid that if I have other options that I have that I can apply.
If the patient is suffering from even a tiny bit of cognitive impairment, for them it can be a little harder to open the device and put the capsule in. If you smash it a little bit, if you don’t puncture it properly, it’s not going to deliver the powder very well. Depending on the weight of the patient who has to use it, they cannot apply it very fast and use strong inhalation because it can cause severe cough. On the other hand, you don’t want to be too shallow that you do not even inhale it at all.
The advantage is it is one of the on-demand therapies that doesn’t need a titration, and this is the reason that several times I just hand it to a patient in the clinic and say, “Just go ahead and use it.” You don’t need to titrate it, you don’t need to prepare the patient, as we do for some others, to prepare the patients for an antiemetic, so we have an option to avoid that. These are pros and cons that I consider regarding levodopa inhalation.
Stuart Isaacson, MD: What have you found when prescribing the inhaled levodopa powder to your patients?
Daniel E. Kremens, MD, JD: The key to successful prescribing of inhaled levodopa is 2 things. The main thing first is that I have to warn them about the cough. It’s not a normal thing to inhale powder into your lungs, right? It takes a little practice. I tell the patients, “You don’t have to suck on it hard. You can just do a gentle deep breath in. You may feel a little tickle from the powder. If you cough a little bit, there’s still a little powder left typically in the capsule that you can take another bit of inhalation to make sure that you’re getting the dose.” I remind them that it’s 2 capsules per dose because some people feel that it may not be as robust and that’s because the dose is about 50 mg equivalent of oral levodopa.
The other key to using new medications successfully is to make sure you take it at the right time. This is not a medicine that I typically would recommend for somebody who’s experiencing a deep OFF. You want to take this at the first sign of the symptoms returning, so you can use it as a bridge. So rather than getting into that deep OFF, when you start to feel yourself turning OFF, you bridge yourself until your next dose of medicine. If you do those, many people are happy with the way the drug works. The other thing that is nice is that it’s pretty convenient. You can carry it with you, and it doesn’t need anything like refrigeration or any special preparations or anything like that. We know that 99% of the patients, 628 out of 629 in the study, were able to use the inhalation after they were instructed.
Stuart Isaacson, MD: Thank you all for joining me and for watching this NeurologyLive® Peer Exchange. I hope you enjoyed the content. Please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.
Transcript edited for clarity.