Assessing Effectiveness of OFF Episode Treatment in PD – Neurology Live

Stuart Isaacson, MD: Laxman, how do you assess whether that treatment worked to work quicker? By avoiding the GI tract, do you get a more rapid ON? What do you do when youre still having a problem? Do you go straight to surgical options, or are there other options that you can think about doing in patients who are hesitant to go through surgical options at that point?

Laxman Bahroo, DO: Its important to assess it. In terms of studies, these therapies are helpful in proving a sooner ON, a faster ON, and maybe even a more reliable ON in many ways. One of the biggest challenges is these are therapies that a patient must administer. If a person doesnt administer it, its not going to work. Many times we have patients who weve given on-demand therapies to, and they still call and complain about OFFs. You say, Why didnt you treat this? They say, I didnt realize that this is what was used for. We talked about that, but we may have talked about it in the context of when theyre treating it in the morning. It never occurred to the patient that they could use it for different times. I always tell them that if you have an OFF episode, this is what the medication is used for. Its designed to bridge you or rescue you, depending on where they are in their OFF, to turn them on.

Many times, I want to get feedback that the therapies are working. Were relying on the patient, but we want their caregiver. Sometimes I want a video of this. Ill tell them when you give yourself an inhaled levodopa or sublingual or subcutaneous apomorphine, send me a video of what you look like as youre taking it. How OFF are you? Sometimes its easier to see if I can see a get-up-and-go test or if I can see what they look like, maybe a 30-second video. Then 10 to 15 minutes later, send me a video of what that looks like. Bring it to the next visit. I want to see how effective it is.

Lets say its not effective. Lets say the first therapy we pickedwhichever 1, lets say the inhaled levodopa or the sublingual apomorphineisnt effective. The first thing I look at is, did you administer it correctly? The administration is the key. Did you administer it early into your OFF period, or did you wait till you absolutely hit OFF and then start it? Maybe it doesnt work as well when you take it much later, especially for the inhaled and the sublingual. Did we administer it correctly? Did we administer the right dose? Did you administer 2 capsules for the inhaled levodopa? Some people say Im only going to do 1 theyre afraid of going to 2, and they felt 1 would be enough.

Did you administer it correctly at the right time? Did you administer the correct dosage? If theyre on the sublingual apomorphine, I tell them that you may be at a starting dose. Starting dose is 10 mg. Maybe we need to advance you. We do that in several ways. The nursing service can do it, we can do it in the office, or we can do it virtually if they have the ability to measure their blood pressure and theres a caregiver at home or a nurse practitioner who can do it. The same thing applies to subcutaneous apomorphine. If youre not on the right dosage, then youre not feeling the full response. To advance that, we have the nurse come to your house and evaluate. Is it a dose technique, do you understand how to inject correctly, are you at the right dosage, or do you just need education on where the OFFs are occurring and how to promptly dose?

Those discussions invariably will involve the provider, the patient, and the caregiver: how to dose correctly, dosing at the appropriate times, using the right dosage. Once weve reached the point where theyre not getting an effective response, then maybe were going to change the baseline. In other words, weve added the on demand, but were not getting a good enough response. Are we undermedicated at other times? If we are, thats fine; we can adjust that. If not, then we can talk about surgical therapies, perhaps a GI [gastrointestinal] infusion like a carbidopa-levodopa solution. Or do we talk about DBS [deep brain stimulation]? Those are the options we have. With those options, theres a gap between our on-demand and adjunct therapies and our surgical therapies.

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Assessing Effectiveness of OFF Episode Treatment in PD - Neurology Live