Practical Considerations in the Management of OFF-Episodes in Parkinson Disease - Episode 1

Overview of OFF Episodes in Parkinson Disease

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Laxman Bahroo, DO, and Sanjay Iyer, MD, define OFF episodes in Parkinson disease and review motor and nonmotor symptoms in patients.

Laxman Bahroo, DO: Hello, and thank you for joining the NeurologyLive® Peers and Perspectives presentation titled, “Practical Considerations in the Management of OFF Episodes in Parkinson Disease.” Today, we’re going to discuss practical considerations surrounding the management and treatment of OFF episodes in Parkinson disease. I am Dr Laxman Bahroo, associate professor in the department of neurology, and the director of both the botulinum toxin clinic and the residency program at MedStar Georgetown University Hospital in Washington, DC. Joining me today is Dr Sanjay Iyer, medical director of the Memory and Movement Center in Charlotte, North Carolina. Thank you for joining us. Let’s begin.

The most important thing to talk about when we’re talking about OFF episodes is to define them and discuss what is an OFF episode. Many folks may be out there wondering what is an OFF episode. Very simply defined, an OFF episode is when Parkinson symptoms return and patients see a return of their symptoms, a reemergence of them. We divide up OFF episodes into 2 big components, motor symptoms and nonmotor symptoms. Motor symptoms can involve tremor, rigidity, slowness of movement, difficulty getting up from a chair, walking, etc. And many times, I use a simple test called the “get up and go” test, and that helps me differentiate what an OFF looks like. Many times, I’ll encourage folks to videotape an OFF so I understand what an OFF means to them, because a picture’s worth 1000 words.

In summary, if you look at OFFs, you need to understand what causes them. There may be many different causes of them, there may be a GI [gastrointestinal] basis behind it, there may be dopaminergic cell loss, and much of our dialogue will talk about different types of OFFs. One prevailing theory is that Parkinson disease is a progressive disorder, we have progressive degeneration of the dopaminergic neurons, and the medications we give aren’t stored as much, and that specifically refers to levodopa, or individuals may need a higher dosage of medication to turn ON. Both the threshold to turn the medication ON, as well as the need for more frequent medications, and the fact that these medications may not be able to be given reliably at the frequent doses that are required, result in an OFF. As I said, there are probably many different causes for OFF episodes. Dr Iyer, what are your thoughts on OFFs?

Sanjay Iyer, MD: I agree, it’s important to establish what OFF means to each patient, as it can be so different, as you alluded to. I often tell my patients, when you take your levodopa, “Can you tell when it’s working? What do you feel that’s different, what gets better,” really track those things. “When does it wear off, when it goes away, what do you feel? That is your OFF.” For some people as you said, it’s more of a motor or physical function, and for some people it’s the nonmotor things. What is interesting is if you spend a few minutes on the front end talking to your patients, a little education, it goes a long way. I’m sure you hear as many times as I do that, “Well, the doctor watched me walk down the hallway and said you’ve got Parkinson disease and handed me this prescription, and I’ll see you in 6 months.” The education is what’s important.

Laxman Bahroo, DO: I agree, education is very important. People need to understand what their medications do for them so they can understand.

Transcript Edited for Clarity