Practical Advice for Managing Morning OFF Episodes in Parkinson Disease


Closing out his review of on-demand therapies for morning OFF episodes in Parkinson disease, Peter A. LeWitt, MD, shares practical advice for community neurologists.


Peter A. LeWitt, MD: In my clinical practice and experience with all 3 on-demand products, that is inhaled levodopa for pulmonary uptake, apomorphine given by subcutaneous injection in liquid form, or apomorphine given in strips that are absorbed through the mucosa under the tongue, each of these has a role to play for certain patients. I use all 3 of them, and some of my patients have tried more than 1 of them. It’s hard to know which will work best for every patient. Some patients may have adverse effects, such as lowering of blood pressure or nausea, with apomorphine no matter how you deliver it. For others, inhaling levodopa will have enough throat irritation or coughing that they choose not to continue with this drug. And apomorphine as a drug is probably more potent than levodopa in the doses that are used as on-demand therapies.

There are several factors that may enter into a decision for a particular patient to choose one or the other. I try to present, in summary fashion, the pros and cons of each of these options, each of which I’ve had a lot of experience with, but a particular patient has had no experience with. I hope that we can convey at least a game plan for what can be tried first, what can be tried next, and perhaps all 3 options might be tested by a patient who is experiencing problems with consistency of levodopa effect, who doesn’t know which one will be their optimum. And in each instance, these therapies tend to work well so we can have confidence that whatever therapy a patient chooses, the likelihood of improving unexpected or troublesome OFF time can be helped. But which one is the best for a particular patient? That is a matter of trial and error.

My specialty is as a movement disorder therapist, so I see a lot of Parkinson disease. I’ve worked with on-demand therapies as a researcher and continue to use these drugs in my clinical practice. For those neurologists who see some patients with Parkinson disease on a regular basis but perhaps don’t have a great deal of experience with the on-demand therapies, my advice would be to become familiar with each of these because I believe there is a niche for each of these therapies among the patients you have.

For those who have needle phobia, if you can explain the fact that the 30-gauge needles for injected apomorphine are as small as what diabetics use and oftentimes patients don’t feel any pain with an injection, that’s one story to tell. The fact that levodopa inhaled doesn’t necessarily cause irritation but must be used properly and practiced is another part of the story. And for those who are using sublingual apomorphine, they must learn to keep it there for 2 minutes, which can be a long wait for somebody, especially if they forget the instructions and discover that absorbing is necessary. If it isn’t absorbed and swallowed, the apomorphine dose may not work for them.

Each of these is a tale to tell your patient to try to get them ON, but the notion of doing the best you can for your patient, of dealing with this very common problem of OFF time or capricious onset of effect, sometimes waiting more than 30 minutes, is a problem that can be solved with current therapeutics. It’s important to think of tuning up your patients with Parkinson disease to improve their quality of life, their confidence that they can go out in the world and not get stuck, that they’ll be safe in outside environments because of these on-demand options for treatment. This is an important option that we now have available, with 3 different choices of drug and delivery system.

Transcript edited for clarity.

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