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What is New in Parkinson’s Disease
Therapy
Monique L. Giroux, MD
Medical Director
Booth Gardner Parkinson’s Care Center
Kirkland, WA
And Northwest Parkinson’s Foundation
Caring for PEOPLE with Parkinson’s disease
and Movement disorders
MoniqueGiroux©2008
Parkinson’s Disease Therapy Outline
 
Current Therapy- Symptomatic therapy
 
Neuroprotection
 
Neurorestorative
 
Unique Populations
MoniqueGiroux©2008
Treatment Goals
  Develop
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a Long-term Strategy
Improve Motor Symptoms
Identify & Treat Associated Symptoms
Minimize/Treat Medication Related Side Effects
Halt Disease Progression, Restore or Enhance
MoniqueGiroux©2008
Idiopathic Parkinson’s Disease
 
Loss of Dopamine Nerve Cells
that project to the Basal
Ganglia
 
 
 
 
 
basis for medical treatment
Slowly progressive
Asymmetric Onset
Affecting mostly people over
60 years
Cause is unknown
MoniqueGiroux©2008
All About Dopamine
 
Current focus of medical therapy is on
motor symptom relief
 
What about nonmotor symptoms
 
What about nonmedical therapy
 
What about disease modification
Current Therapies for Parkinson’s
Disease
COMT = catechol-O-methyltransferase; MAO-B = monoamine oxidase B
Current Medical Therapy
 
Dopaminergic therapy- improve motor
symptoms
 
Reduce dyskinesia or on-off fluctuations
 
Disease Modification
Symptom Control
 
Improve movement symptoms
Dopamine Therapies
Throughout Life
Treatment Goal = Dopamine Management
Disease Progression
•  MAO-B inhibitor
•  Dopamine agonist
•  Amantadine
•  Levodopa
• 
• 
• 
• 
MAO-B inhibitor
Dopamine agonist
Levodopa
COMT inhibitor
• 
• 
• 
• 
• 
MAO-B inhibitor
Dopamine agonist
Levodopa
COMT inhibitor
Apomorphine
Many therapeutic agents may be required over the course of the patient’s
disease to maintain patient function
MAO-B = monoamine oxidase type B; COMT = catechol-O-methyltransferase.
Schapira. Arch Neurol. 2007;64:1083-1088.
Olanow et al. Neurology. 2001;56(11 suppl 5):S1-S88.
9
Snyder et al. J Am Acad Nurse Pract. 2007;19:179-197.

From Reaction to Pro-action
 
Disease Modification
Disease Modifying
 
Change the expected
  Early
use of agonist can delayed or reduce
Ldopa induced fluctuations and dyskinesia
dyskinesia
  Early
Use of Rasagiline shows long-term
promise
  Deep
brain stimulation reduces off periods,
dyskinesia and tremor
Disease Modifying
 
Change the expected
  Early
use of agonist can delayed or reduce
Ldopa induced fluctuations and dyskinesia
dyskinesia
  Early
Use of Rasagiline shows long-term
promise
  Deep
brain stimulation reduces off periods,
dyskinesia and tremor
Agonists delay or reduce onset of
dyskinesia after 4-5 years
 
Motor Complications
 
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Modifiable Factors
 
 
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Ldopa - 50-60% of patients will develop motor complications
within 5 years
Up to 16% develop after one year on higher dose Ldopa
Pulsatile Stimulation- Longer half life
Total Ldopa Dose – Adjuvant therapy
Agonists used early can delay
 
 
Ropinirole (Requip)
Pramipexole (Mirapex)
Study of REQUIP® (ropinirole HCl) vs.
L-Dopa as Initial Therapy
Dyskinesia in All Patients Regardless of L-Dopa Supplementation
MoniqueGiroux©2008
Early use of agonist
Not for everyone!
 
Increased risk of
  Sedation
  Confusion
and hallucinations
  Impulsivity control
  Low blood pressure
Age Related concerns
 
 
Old Onset:
  Lower risk of dyskinesia and fluctuations
  Higher cognitive risk or confusion
  Comorbid medical Problems
  Gait Disorder
  Consider Ldopa
Young Onset:
  Greater risk of developing dyskinesia,
fluctuations
  Dystonia: i.e.: foot dystonia
  Consider Ldopa Sparing Response
MoniqueGiroux©2008
Initial therapy considerations
Motor complications vs. risks of agent
Risk < Ldopa
  Agonists
  MAO B InhibitorRasagiline, Selegeline
  Amantadine
  Anticholinergics
Side effects > Ldopa
  Agonist- cogntive,
halluciantions, sedation,
impulsivity control
 
Eldepryl- amphetamine
related side effects
 
Amantadine and
Anticholinergics
MoniqueGiroux©2008
Disease Modifying
 
Change the expected
  Early
use of agonist can delayed or reduce
Ldopa induced fluctuations and dyskinesia
dyskinesia
  Early
Use of Rasagiline shows long-term
promise
  Deep
brain stimulation reduces off periods,
dyskinesia and tremor
Rasagiline and Disease Modification
 
Early Use of Rasagiline shows long-term benefit
 
Delayed Start Experiment
 
Questions Introduced
 
Should treatment begin with onset of motor symptoms?
 
Is it harmful not to treat?
Symptomatic vs. Disease-Modifying
Effect
Delayed-start
Delayed-start
catches up
Time
Symptom
improvement
Delayed-start
Delayed-start
does not catch up
Time
Symptom
improvement
Disease Modifying
Delayed Start paradigm mild patients treated early did better at
18 months then those that delayed treatment 9 months.
Disease Modifying
Don’t Forget The Obvious
Exercise
  Support
  Nutrition
  Emotional Health
  Spiritual Support
 
Dopamine Management
Throughout the Course of PD

Disease Progression
•  Wellness
•  MAO-B inhibitor
•  Dopamine agonist
•  Amantadine
•  Levodopa
•  Wellness
•  MAO-B inhibitor
•  Dopamine
agonist
•  Levodopa
•  COMT inhibitor
•  Wellness
•  MAO-B inhibitor
•  Dopamine
agonist
•  Levodopa
•  COMT inhibitor
•  Apomorphine
Many therapeutic agents may be required over the course of the patient’s
disease to maintain patient function
MAO-B = monoamine oxidase type B; COMT = catechol-O-methyltransferase.
Schapira. Arch Neurol. 2007;64:1083-1088.
Olanow et al. Neurology. 2001;56(11 suppl 5):S1-S88.
24
Snyder et al. J Am Acad Nurse Pract. 2007;19:179-197.
Treating Nonmotor symptoms
 
Nonmotor therapies- significant
contribution to QOL
 
Focus on motor symptoms alone is not
enough
Symptoms of Parkinson’s Disease1-5
Motor symptoms
 Tremor
at rest
 Bradykinesia
 Rigidity
 Postural
 Other
Nonmotor symptoms
 Neuropsychiatric
(eg, dementia,
cognitive decline, depression,
anxiety, psychosis, apathy)
 Sensory
instability
(eg, dysarthria, shuffling
gate, dystonia)
(eg, hyposmia, pain,
paresthesias)
 Sleep
disturbances (eg, RBD,
RLS, sleep apnea, sleep attacks,
daytime somnolence, insomnia)
 Autonomic
 Other
dysfunction
(eg, fatigue, weight loss)
RBD = rapid eye movement behavior disorder; RLS = restless legs syndrome.
1. Berg. Neurodegener Dis. 2008;5:133-136. 2. Jankovic. J Neurol Neurosurg Psychiatry. 2008;79:368-376. 3. Thanvi et al. Postgrad Med J.
2003;79:561-565. 4. Weintraub et al. Am J Manag Care. 2008;14:S40-S48. 5. Zesiewicz et al. Expert Rev Neurother. 2006;6:1811-1822.
Stages and Brain Changes
 
Stage 1: DMV and olfactory bulb
 
Stage 2: Lower brainstem, including
pons (medullary raphe, magnocelluar
portion of reticular formation,
and
LC)
 
Stage 3: Amygdala, magnocelluar
nuclei of the basal forebrain, and pars
compacta of SN
 
Stage 4: Olfactory telencephalic cortex,
temporal mesocortex
 
Stage 5: Sensory association areas,
prefrontal fields of neocortex
 
Stage 6: Primary fields of neocortex
Nonmotor therapies
 
Cognitive problems- rivastigmine, donepizol, memantine, exercise,
cognition, support/social
 
Hallucination- quetiapine, clozapine, cognition, medication needs,
other stress, manage
 
Depression/anxiety- antidepressants, sedatives, behavioral
management, exercise, diet, supplements
 
Neurogenic bladder- antispasmodic medicines, bladder therapy with
PT/OT
 
Neurogenic bowel- diet , exercise, medicine, supplements
 
Blood pressure fluctations- florinef, midodrine, diet, fluids, stockings,
movement, sleep
Changing the forecast
 
Neuroprotection
 
Neurorestoration
 
Prevention
Neuroprotective Therapy: Definition
Therapy that combats the underlying
neurodegenerative mechanisms in
order to halt or slow progression of
PD and to promote the preservation,
rescue, or restoration of lost neurons
PD = Parkinson’s disease.
1. Shoulson. Mov Disord. 1998;13:46-48. 2. Mandel et al. CNS Drugs. 2003;17:729-762. 3. Schapira. Eur J Neurol. 2008;15:5-13.
Premotor Biomarkers – earlier
diagnosis essential in
neuroprotection
Strong link to PD
 Olfactory
dysfunction1,2
 RBD3-5
 Autonomic
dysfunction (eg,
constipation,6 MIBG uptake
on heart scan7,8)
 Depression9-12
Weak link to PD
 Excessive
daytime
sleepiness13
 Adiposity14,15
 Apathy16
 Fatigue16,17
 Anxiety12,16,18
 RLS16
MIBG = metaiodobenzylguanidine; RBD = rapid eye movement behavior disorder; RLS = restless legs syndrome.
1. Ponsen et al. Ann Neurol. 2004;56:173-181. 2. Ross et al. Ann Neurol. 2008;63:167-173. 3. Hickey et al. Neurologist. 2007;13:98-101. 4. Iranzo et al.
Lancet Neurol. 2006;5:572-577. 5. Schenck et al. Neurology. 1996;46:388-393. 6. Abbott et al. Neurology. 2001;57:456-462. 7. Braune. Clin Auton Res.
2001;11:351-355. 8. Yoshita. J Neurol Sci. 1998;155:60-67. 9. Lauterbach et al. J Neuropsychiatry Clin Neurosci. 2004;16:29-36. 10. Nilsson et al. Acta
Psychiatr Scand. 2001;104:380-386. 11. Schuurman et al. Neurology. 2002;58:1501-1504. 12. Shiba et al. Mov Disord. 2000;15:669-677. 13. Abbott et al.
Neurology. 2005;65:1442-1446. 14. Abbott et al. Neurology. 2002;59:1051-1057. 15. Chen et al. Am J Epidemiol. 2004;159:547-555. 16. Chaudhuri et al.
Lancet Neurol. 2006;5:235-245. 17. Schifitto et al. Neurology. 2008;71:481-485. 18. Weisskopf et al. Mov Disord. 2003;18:646-651.
Therapeutic Possibilities- More than Just Dopamine
Dyskinesia
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Nicotine- reduced risk, prevents protein
aggregation, improve symptoms and reduce
dyskinesia
Fipamezole- alpha adregeneric agent studied to
reduce dyskinesia
Levetiracetam- small studies to date, study to
evaluate effect on dyskeinsia
NEU 120- NMDA antagonist and MAOB inhbitor
Safinamide
Kynurenine- NMDA antagonist
Neuroprotective Strategies
 
Apoptosis- programmed cell death
 
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Antioxidants
 
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Amantadine,
Neuroimmuniphilin- immunosuppressant drug
 
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CoQ10, Glutathione, Green tea, tumeric
Excitotoxicity- Antiglutamate
 
 
Minocycline, CEP 1347
GP 1485
Neurotrophic factors- promoe cell growth
 
GDNF, Nurturin
Therapeutic Possibilities- More than Just Dopamine
Neuroprotection
 
Nicotine- reduced risk, prevents protein aggregation, improve
symptoms and reduce dyskinesia
 
CoQ10increase dose range studied
 
Creatine- energy function. neuroprotective trial underway
 
Vitamin D – lower in PD, lower walking speech and cognitive
changes
NEU 120- NMDA antagonist and MAOB inhbitor
Safinamide- MAO B
Rasagiline- MAO B inhibitor.
Isradipine- blocks L type Ca++ to reduce oxidative stress
Adenosine blockers- SYN 115, Sch 420814
K
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Potential Neuroprotective Therapies
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Exercise
ADAGIO follow-up study– Long-term effect of
rasagiline in patients with PD
• Oxidative stress/uric acid
• Neurotransmitter targeting
–VMAT2 (vesicular monoamine transporter
2)
–Anti Glutamate
•Modifying dopaminergic neuron apoptosis
TCH346
Caspase inhibitors
MoniqueGiroux©2008
Neurorestorative Therapies
 
Transplant
  Gene
therapies-
Growth factors
  Dopamine Enhancement
  Antiglutamate
 
 
Stem Cell
Tools for Health
and Wellbeing
www.nwpf.org/wellness