“Updates in Parkinson’s Disease” – Webinar Notes

“Updates in Parkinson’s Disease” – Webinar Notes

The American Parkinson Disease Association (APDA) Connecticut Chapter hosted a webinar in early January 2021 on new medications and therapies for Parkinson’s disease (PD). The speaker was Lean Meytin, MD, Movement Disorder Specialist at Hartford Healthcare in Hartford, CT. He discussed the current treatment landscape for PD, including newly approved medications, and answered audience questions.

Dr. Meytin began his lecture by defining Parkinson’s disease: a slowly progressive neurological condition due to the loss of dopamine within the brain. There are many types and subtypes of PD, and no two people with PD are alike.

He discussed three new medications for increasing ON time and two new rescue medications.

He also addressed medications and a surgical treatment on the horizon. 

Lastly, Dr. Meytin answered audience questions about the new treatments, as well as general questions about Parkinson’s disease. Here are 3 questions regarding levodopa:

Q.   Does avoiding taking Levodopa/Carbidopa around meals help or not help?

A. Sinemet should not be taken around the time of a large protein meal. When you take both by mouth, they actually kind of fight for the ability to get absorbed. Take Sinemet about half an hour before a large protein meal, like a steak. Or you can take Sinemet an hour after eating. A carbohydrate-based meal like pasta shouldn’t have an effect on levodopa. 

Q.   When you’re newly diagnosed, should you avoid Levodopa/Carbidopa at the beginning?

A. There’s no reason to not take Sinemet. The Sinemet does not slow down the Parkinson’s, but it does not make it worse. There’s no reason to not take it if you need it. Your Parkinson’s will still progress, and you may need higher doses of Sinemet, but that is to do with the advancement and duration of your Parkinson’s and not because of the Sinemet.

Q. My wife breaks out with a rash when she takes Levodopa/Carbidopa. What should she do?

A. That’s a tough one because it can be a specific condition to her. I would need to know more about her symptoms, etc., as well as the severity of her rash. Pramipexol is a reasonable alternative, but again, it depends on her. 

The webinar was recorded and can be found on the APDA YouTube page here.

Stanford Parkinson’s Community Outreach has a lot of resources on PD medications here.

I listened to this webinar and am sharing a summary below.

– August Besser


“Updates in Parkinson’s Disease” – Webinar Notes

Speaker: Leon Meytin, MD, movement disorder specialist, Hartford Healthcare, Hartford, CT

Webinar Host: American Parkinson Disease Association- Connecticut Chapter

January 13, 2021

Summary by August Besser, Stanford Parkinson’s Community Outreach

Parkinson’s Disease (PD)

  • SLOWLY progressive neurological condition
  • Due to the loss of dopamine partly due to abnormal clumping of a protein called alpha-synuclein
  • Many types and subtypes – no two patients are alike!

Treatment

  • Levodopa, otherwise known as Sinemet is the gold standard
  • Currently taken 3-6 times per day
  • Symptomatic treatment only – does not slow down PD
  • Duration: 2-6 hours
  • 2 main problems: “wearing off” and “delayed kick-in”

New Medications for Improving “ON” time

  • 30 – 60 minutes of increased “ON” time
  • Xadago (Safinamide): “cousin” of Azilect (rasagiline), or Selegiline. Mechanism: MAOb inhibitor
  • Nourianz (Istradefylline). Mechanism (unique mechanism): Adenosine A2A Receptor blockade
  • Ongentys (Opicapone): “cousin” of Comtan (entacapone), but longer lasting. Mechanism: COMT inhibitor

Rescue Medications

  • As needed medication when Sinemet is not working well enough
  • Both new agents kick-in within 10-30 minutes
  • Kynmobi (ODT apomorphine). Same medication as Apokyn. Route: under the tongue/dissolvable medication. Mechanism: Dopamine agonist.
  • Inbrija (inhaled levodopa). Route: inhaled. Mechanism: Levodopa. Same as Sinemet.

What’s on the Horizon?

  • Levodopa patch pump
  • Alpha synuclein therapies
  • Genetic Parkinson’s 
  • Viral Vectors
  • Surgical Options

Levodopa Patch Pump

  • Two companies in Phase 3 trials (near the end of trials, close to being released to the public).
  • Same levodopa given to many people with PD
  • Tiny amounts injected throughout the day; not a pill taken by mouth
  • Size of the device varies by company

Alpha Synuclein Therapies

  • Two ways of “attacking” alpha synuclein
    • Vaccines – the goal is to have your own body fight off the alpha synuclein
    • Antibodies – we introduce something that will fight off the alpha synuclein
  • Both therapies are in Phase 2 trials
  • These treatments can also help with Lewy Body Dementia (LBD)

Genetic Parkinson’s

  • Many genes associated with PD
  • Two common genes: LRRK2 and GBA
  • Just because you may have these genes, does not mean that you will develop PD later in life
  • Phase 1 and Phase 2 studies in clinical trial

Viral Vectors

  • AADC: increases dopamine production in the brain
  • GDNF: thought to play a neuroprotective role in the brain
  • Uses a virus to insert medication into the brain without causing harm to a person
  • This method is applied to cancer, Alzheimer’s, etc.

Surgical Options

  • Deep Brain Stimulation (DBS): Place a very tiny electrode in the brain connected to a pacemaker; interrupts abnormal cycle contributing to PD
  • Focused Ultrasound (FUS): Use ultrasound waves to interrupt abnormal brain cycle; similar to DBS but without surgery or electricity. Has not yet been approved for PD.

Question and Answer

Q.   Do the new DBS batteries have a longer life span than those from 5 years ago?

A. Yes, the new batteries are more efficient. We have also improved the device to last longer and work more efficiently. We also have rechargeable batteries for DBS for those who want them.

Q.   How long will the ultrasound treatment last?

A. That’s the problem with the FUS treatment. We only have data for the essential tremor condition, and while it is similar to PD, there are some differences. Some studies are 3-year studies (from the time of the surgery to 3 years after), and can tell you results for essential tremors for that period. But not yet for 5 or 10 years. We also don’t know what will happen with PD and focused ultrasound treatments, if it will help the Parkinson’s or make it worse.

Q.   If I don’t respond well to medications, should I consider DBS?

A. It depends on what you mean by “don’t respond well to medications.” We have to take a step back and look at what’s going on. Are you reacting to the medication, or not reacting at all? Have you developed side effects? Deep brain stimulation only really works for people who respond well to levodopa. If you don’t respond to levodopa, we don’t usually do surgery because then you wouldn’t respond to DBS. But there are various ways to safely get the medications into your body even if you have taken them in the past and the meds haven’t been successful. 

Q.   Can you comment on new methods for treating non motor symptoms?

A. It really depends on which non motor symptom we are focusing on. Some respond to the same medications that we use for motor symptoms. For example, anxiety is a very common non motor symptom for people with PD. I always use a multidisciplinary approach with social workers, movement disorder specialists, in order for all of us to put our heads together and decide how to treat this person holistically.

Q.   Can I get tested for the abnormal genes and also the protein clusters?

A. Yes, we can test for some of the abnormal genes. Some genes we still do not know if they are linked to PD. Be careful with home genetic testing kits like 23andMe, because they do not test for everything related to PD. 

R.    Does avoiding taking Levodopa/Carbidopa around meals help or not help?

A. Sinemet should not be taken around the time of a large protein meal. When you take both by mouth, they actually kind of fight for the ability to get absorbed. Take Sinemet about half an hour before a large protein meal, like a steak. Or you can take Sinemet an hour after eating. A carbohydrate-based meal like pasta shouldn’t have an effect on levodopa. 

R.    When you’re newly diagnosed, should you avoid Levodopa/Carbidopa at the beginning?

A. There’s no reason to not take Sinemet. The Sinemet does not slow down the Parkinson’s, but it does not make it worse. There’s no reason to not take it if you need it. Your Parkinson’s will still progress, and you may need higher doses of Sinemet, but that is to do with the advancement and duration of your Parkinson’s and not because of the Sinemet.

Q. My wife breaks out with a rash when she takes Levodopa/Carbidopa. What should she do?

A. That’s a tough one because it can be a specific condition to her. I would need to know more about her symptoms, etc., as well as the severity of her rash. Pramipexol is a reasonable alternative, but again, it depends on her. 

Q.   Are there any suggestions on how to manage dyskinesias?

A. Yes. For those who aren’t aware, dyskinesia is excessive “wiggly” movements. It can be a troubling and surprising symptom for people with advanced PD. If the dyskinesia is not personally bothersome, we don’t actually do too much with it. There are specific medications we can use to treat the dyskinesia, but those have their own side effects. One common medication is called Amantadine, which is very effective at treating dyskinesia.