Practical Advice on the Management of PD OFF Episodes

Peter A. LeWitt, MD: As a Parkinson disease specialist with a practice that has more than 1000 patients, I've had a lot of experience with the problem of delayed ON and other motor fluctuations for which an on-demand therapy like apomorphine is appropriate. General neurologists who see a few patients with Parkinson disease who don't have that day-by-day experience might not have as much interest in being overly invasive with therapies such as an on-demand injectable drug like apomorphine.

It's important to think that the ball is in your court. The buck stops with you. When a patient with Parkinson disease is coming to you and is getting gradually worse over the years, there are certain interventions that we can use. We can't help with the problem of balance. Sometimes posture change is also impervious to therapy with medications.

But OFF episodes do have something that can be treated. Encouraging a patient to look at their medication schedule, trying out extra levodopa intake, and trying a dopaminergic agonist or levodopa extended release are all easy to do. They either work or they don't. The patient can get back to you in a few weeks as to whether that intervention has worked. Polypharmacy makes sense in Parkinson disease if it achieves reasonable goals.

Because quality of life is very much tied to optimization of medication, make this a priority, especially for a patient who is still working and whose quality of life and independence are in jeopardy. If there is a problem where he is stumbling and falling, that makes it a concern regarding whether a patient should be living alone. These are issues that are somewhat nonemergency problems, but close to it, especially if patients have the option of changing their medication for the better.

I would encourage looking at OFF episodes as a very treatable part of Parkinson disease. We have a couple of methods that can simultaneously help. Sometimes I create a sequence of changes in medications in a visit with the thought that in 4 or 5 months, when the patient returns, I'll have some answers by then from a simple phone call or an email.

In the case of apomorphine as an injection, the home titration service that is bundled into the product as we prescribe it has been very effective in finding out whether a patient can tolerate it safely. There's great skill in terms of that home nurse who talks to patients to give feedback and go over the details of how to put a needle on the syringe, dial in the dose, and make the best use of caregivers, if necessary.

I think you'll find this is a very satisfactory treatment option for many patients who have not even heard of this before. I find it very odd that many patients who even been to other Parkinson disease specialists haven't been told that there is the option of on-demand therapy, whether the inhaled levodopa product or apomorphine. I encourage my colleagues to think of this as something that should be brought up in discussion. Even if you're not prescribing it for your patient at that visit, it might be something necessary in the future.