Robert Hauser, MD, MBA, shares his expertise in the treatment of OFF time in Parkinson disease.
Robert Hauser, MD, MBA: For patients who are experiencing OFF time, we have quite a few options. For patients who are on 3 carbidopa/levodopa immediate release [doses] per day, it’s very common for health care providers to increase that to 4 times a day, and that works pretty well initially. However, once you go beyond 4 immediate release carbidopa/levodopa per day, things get pretty difficult. First of all, compliance goes down when you’re taking pills that frequently and also in patients who go up to 5 or more immediate-release carbidopa/levodopa pills per day. These are the patients who are experiencing that very short duration of benefit, typically benefits lasting only 2 and a half hours or so. And they’re also experiencing this variability as to when that good ON will occur. So I think once you get past 4 immediate-release carbidopa/levodopa [doses] per day and you need to do something more, that’s a time to think about what else is available. There are a number of adjunct medications that can be added. And then there are a number of so-called on-demand therapies for patients that can be considered as well. For dyskinesia, there’s only 1 medication that’s indicated for the treatment of dyskinesia, and that’s amantadine extended-release capsules. Interestingly, that’s also indicated for the treatment of OFF. So I would say it certainly comes to top of mind if you’re dealing with a patient who has both OFF and dyskinesia, even if it’s a little bit of dyskinesia, because all those other treatments, if you’re dealing with a patient who has OFF and has a little bit of dyskinesia, if you’re going to add on more dopaminergic medication, they’re going to experience more dyskinesia. So if it’s the appropriate patient who has good cognition, doesn’t have any history of hallucinations, even if they have just a little bit of dyskinesia, if you’re trying to treat OFF, I would think about adding amantadine extended-release capsules.
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