Expert neurologists provide insight on how to decide on an on-demand therapy for Parkinson’s disease and provide some general advice.
Stuart Isaacson, MD: How do you decide which on-demand therapies to begin when you want to treat somebody’s morning OFF?
Laxman Bahroo, DO: It’s a collaborative decision. I have to vest the patient or the patient’s caregiver into this. If I don’t, we probably won’t have good adherence to medication. I want to get an idea of what their goals are and give them an idea of what the medication expectations are, and we meet somewhere in the middle. If I have somebody who is mildly OFF but needs enough to be able to get going, I might use 1 therapy that is an inhaled or a sublingual option.
If I have somebody who’s fully akinetic, who can’t move or can barely move, then we’d probably go with the subcutaneous option. Stratifying by severity is very important. It’s equally important to stratify based on use. Not every therapy can be given to everybody equal in the same situation. If a patient can’t take therapy on their own, they can’t take the inhaled. It requires them to do the process but to be able to actively inhale the medication. If they can’t inhale the medication, it does them no good.
At a bare minimum they have to be able to open their mouth and put a strip under their tongue, and to be able to hold that without swallowing it. In the most passive patient who isn’t able to cooperate, the spouse or caregiver can give them a subcutaneous injection. With these factors, the answer presents itself. If it doesn’t present itself, you could at least discuss the choices within individuals, and then they vest in the decision of saying, I’ll choose A. If A doesn’t work, I’ll chose B. At least you have a paradigm to work with for that individual patient.
Stuart Isaacson, MD: What advice do you have for community neurologists who may be initiating on-demand therapies in particular. How do you decide which drug to use specifically?
Daniel E. Kremens, MD, JD: My first piece of advice to the neurologist who isn’t as familiar with on-demand therapies is to point out how it’s been a paradigm shift. This is something that as a neurologist you’re probably comfortable with already. That’s the notion of how we treat migraine: we don’t treat migraine with prophylactic therapies only; we use abortive therapies as well. Neurologists are comfortable doing that. We’re seeing this now in Parkinson disease. We can use the longer-acting preparations for prophylactic and then use the on-demand therapies for abortive therapies in Parkinson disease. That’s a paradigm shift that I encourage the nonmovement disorder community to embrace.
The second thing I recommend to them is don’t let the lack of trimethobenzamide, or Tigan, be a barrier to using the drug. Many of us have experience with this, and there are lots of data—as Bill’s study showed and some other studies have showed—that you can initiate these drugs safely without an antiemetic drug. If you go low and slow, you can use these medications.
The final point is what medication do I choose. It’s an individual discussion with that patient. Each of the medications has advantages and disadvantages, and it comes down to how will that medicine fit into that patient’s lifestyle, taking into the fact that you want something rapid, reliable, robust, and convenient. Looking at those together, what works for that patient?
Khashayar Dashtipor, MD: As I said before, even in case 2, emphasize on-demand. What’s missing in our fill for the general neurologist is recognition of OFF episodes. My position for them is that our goal in Parkinson disease is minimizing OFF, and if it’s possible, to get it to 0.
On-demand therapies are 1 of the tools, and patients can use it as needed. Therefore, they should get familiar with on-demand therapies as 1 of the tools we have to treat OFF episodes.
Because there’s a lack of head-to-head studies, the best way is to get their hands into different ones—there are 3 available, and they come up being able to introduce it to their patients. In less than 1 minute, I review the complexity, the efficacy, and the adverse effect of each. Then I classify for my patient and then let them decide. But it’s best for the general neurologists to get familiar with medication as well.
William G. Ondo, MD: I absolutely agree that OFF episodes are underrecognized. To get a clear pattern, it sometimes does take a couple of minutes of conversation. I’ve seen general neurologists make this mistake where they give these drugs when the patients are on. You do have to make sure, especially in the apomorphine preparations in which we’re trying to dose these medications. You have to know how to artificially let them come off to be able to determine the optimal dose.
Stuart Isaacson, MD: Educate your patients somewhat on what OFF is and what symptoms they have, motor and nonmotor. Ask about them routinely, including all types of OFF, like morning OFF. Be aware that when they’re taking levodopa or extenders, these on-demand therapies can work more rapidly and reliably and can work as robustly as levodopa to turn patients from OFF to ON.
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Transcript edited for clarity.