THE FOX FOCUS...
ON RESEARCH
DR. DOLHUN
TALKS PD
TARGETING “OFF” TIME:
NEW TREATMENTS TO LESSEN
MOTOR FLUCTUATIONS
In January, the U.S. FDA approved two new formulations of the “gold standard”
traditional Parkinson’s treatment carbidopa/levodopa. Duopa and Rytary are designed
to lessen “off” time — when symptoms return prior to the next scheduled dose of
medication. Rytary is an oral extended release capsule and Duopa is a gel formulation of
carbidopa/levodopa infused directly into the small intestine. (Learn more on page 11.)
Dr. Rachel Dolhun, MJFF’s resident movement disorder specialist, sat down with
Claire Henchcliffe, MD, a movement disorder specialist in clinical practice at New YorkPresbyterian Hospital/Weill Cornell Medical Center to discuss “off” times and strategies for
optimizing treament.
Dr. Rachel Dolhun: In my practice,
patients often had difficulty recognizing
and describing wearing off symptoms
because they are so individualized and
can be so varied. Do you see this in
your clinic?
Dr. Claire Henchcliffe: My patients do
exhibit a wide range of symptoms — both
motor and non-motor — when wearing off.
They also differ with regard to the rate of
onset — symptoms can come on gradually
or appear suddenly and unpredictably.
Some people have a vague sensation of
generalized fatigue in the afternoons, or
subtle mood changes or profuse sweating
prior to taking their pills. In these cases, it
takes a bit of probing to figure out that this
is actually “off” time. Others experience
a more distinct return of resting tremor or
localized dystonia and pain before their
6 THE FOX FOCUS
next medication is due. It can be hard for
patients to determine what is and isn’t part
of Parkinson’s.
RD: As you mentioned, correctly
diagnosing wearing off required a good
amount of discussion with some of my
patients. Once we determined
symptoms were from wearing off, there
were multiple options for treatment,
including lifestyle and medication
adjustments. What is your typical
approach to management?
CH: Treatment is, of course, tailored to
each person. First, I address behaviors that
might be making medication less effective
— such as missing or accidentally delaying
scheduled drug doses, eating a lot of
protein before a dose, or taking
carbidopa/levodopa with meals. If that’s
not enough, it’s then possible to adjust the
dosage of medication and/or the timing
of administration, and also to consider
adding another drug to the medication
regimen.
RD: I, too, tried to optimize a patient’s
current therapies before prescribing
another medication when treating
wearing off. At times, however, this led
to frequent dosing of carbidopa/levodopa that became too cumbersome.
Do you think there will be an opportunity to replace what patients are taking
now with the new formulations of
carbidopa/levodopa?
CH: I certainly see a place for these drugs
in my clinic. Both are designed to deliver a
more steady concentration of medication
and therefore lessen off time. I see Duopa
as an alternative to deep brain stimulation
(DBS) in those with uncontrolled motor
fluctuations who either don’t want DBS or
aren’t ideal candidates for it. I anticipate
using Rytary in my patients with advancing disease or those who have inadequate
control on their current medications. I hope
the new formulations will lighten the
number of medication doses required per
day, decrease the number and severity of
off periods, and eliminate the need for
rescue \