Thomas L. Davis, M.D.

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Parkinson Disease 2008

• Thomas L. Davis, M.D.
• Associate professor of Neurology
• Medical Director, Vanderbilt NPF COE

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Conflict of Interest

• Medtronic
• GlaxoSmithKline
• Novartis
• Teva
• Valeant
• Boehringer Ingelheim
• UCB
• Ipsen

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Are there any new medications available for
Parkinsons disease?
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What happened to the patch?

• Neupro patch (rotigitine) was the first patch
  medication approved for the treatment of
  Parkinsons disease
• Problem with the manufacturing process led to the
  formation of crystals in some patches. The
  crystals would interfere with the absorption of
  the drug such that a patch with crystals would
  deliver only a partial dose.
• UCB electively withdrew the dug from the North
  American market until the problem can be solved.
• It is still available in Europe, it is not know
  when or whether it will return to the American
  market.
• Sinemet is not absorbed through the skin but
  attempts are being made to reformulate it.

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What about the new Stalevo?

• Stalevo is a combination medication containing 3
  drugs
• levodopa
• carbidopa
• entacapone (Comtan).
• All formulations of Stalevo contain 200mg of
  entacapone
• New Stalevo 200 soon to be available in 75, 125.

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What is that new Requip?

• Generic Ropinirole (Requip) is now available.
• Requip XL is a new once a day oral formulation of
  Requip that is not available in a generic.
• The daily dose of the extended release
  preparation is the same as the regular
  formulation although it is hoped that the
  extended release formulation may allow for a
  higher dose.

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What is the new medication for memory loss in PD?

• Exelon is approved for the treatment of memory
  loss associated with PD. It is now available in
  both a pill and a patch.
• Exelon is one of 3 medications in the class
  called cholinesterase inhibitors that are also
  improved to treat memory loss in Alzheimers
  disease.

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Are there any new clinical observations in PD?
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Hypophonia

• Many patient with PD experience a decreased
  volume to their voice that is unresponsive to
  medical treatment.
• Speech Therapy (the Silverman method) has been
  advocated to treat hypophonia.
• Recent evidence suggests that part of the
  hypophonia is misperception of voice volume by
  the patient

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Placebo Effect in PD

• Recent evidence shows that the anticipation of
  receiving treatment releases dopamine in the
  brain.
• This release of dopamine can provide symptomatic
  relief
• This complicates interpretation of clinical
  trials and clinical usefulness of medications.

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Impulse Control Disorder

• Recent survey study shows that medications used
  to treat PD may trigger impulse control disorder
• Impulse control
• Shopping
• Gambling
• Sexual activity
• Hoarding
• All medications may cause dopamine agonist may
  be slightly more likely than others.

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Exercise in Parkinsons Disease

• All recent studies of exercise in PD have shown
  that regular exercise helps to delay disability
• The type of exercise seems to less important than
  the time spent doing it.
• Symptomatic medication should not be withheld for
  treatment of future disease progression.

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Are there any clinical trials in PD?
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Vanderbilt NET-PD

• NET- PD Neuro-Exploratory Trials is a multicenter
  NIH sponsored trial to screen and test for
  potential neuroprotective treatments for PD
• To date they have screened creatine, CoQ10,
  GPi-1486.
• Creatine is now in a larger trial.
• Disease

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Vanderbilt Brain Atlas

• Small changes in location of DBS electrodes lead
  to big changes in clinical response.
• Many of the targets for DBS are not directly
  visible on MRI scanning.
• Advances in brain scanning and image analysis
  could lead to improved outcomes for those
  undergoing DBS surgery.

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PPN Stimulation
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Vanderbilt Wii

• Treatments for the motor disability associated
  with PD classically make use of rating scales.
• More objective measure of tremor, speed of
  movement, and gait may speed drug development by
  requiring fewer subject per trial.
• Accelerometers have long been used to quantify
  movement.

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Accelerometers
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Foot Tapping
UPDRS 0
UPDRS 3
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Finger Tapping
Normal
PD
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Vanderbilt Cognitive Therapy Project

• There is increasing evidence that just as
  physical activity preserves motor function,
  mental exercise may preserve memory and other
  cognitive functions.
• Although a number of puzzles exist, most of these
  are too long or too difficult for patients with
  cognitive impairment.
• Specialized cognitive therapy is often
  prohibitively expensive.

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VCTP

• Need Puzzle authors
• Puzzles are made using HOT Potatoes
• Cross word
• Multiple choice
• Fill in the blank
• Sentence Scramble
• Matching
• Need Puzzle takers
• VCTP Newsletter

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Vanderbilt Pluriopotent Stem Cell Program
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Vanderbilt Early DBS Trial

• DBS is an effective treatment for controlling
  medication induced motor fluctuations and
  controlling drug resistant tremor in PD.
• DBS surgery may make memory worse and surgery is
  not recommended in those with significant memory
  problems.
• Big Question Would patients be better off in
  the long run if they underwent DBS surgery
  earlier in the course of their disease?
• Current Question Is DBS surgery safe in early
  PD?