The complex Parkinson’s patient

This year’s Neurology Update Meeting, organised by the Irish Institute of Clinical Neuroscience, took place in the Canal Court Hotel, Newry, Co Down, on 11 October, under the directorship of Dr Ferghal McVerry.

Dr McVerry, Consultant Neurologist, Altnagelvin Hospital, Co Derry, opened proceedings by welcoming guests, chairpersons, delegates and sponsors to the meeting. A special word of thanks was extended to Dr Junie Koay and Dr Antoinette O’Connor who both agreed to speak at short notice.

Dr McVerry chaired the opening session. The first lecture was delivered by Dr Laura Best, Consultant Neurologist, the Royal Victoria Hospital, Belfast. The title of Dr Best’s talk was ‘The complex Parkinson’s disease (PD) patient: When to consider advanced therapies’.

She advised attendees to refer early for advanced therapies if they think patients might benefit.

“If you take too long doing the pragmatic approach… you might miss the boat,” Dr Best told the Medical Independent (MI) after her talk.

“Some of these patients do remarkably well with advanced therapies. And it can have a life-changing effect. It can have a massive improvement on quality-of-life for them and their carers. So, I think the take home message of my talk is, if you are not winning, it usually means they need something else. And refer early rather than late.”

Dr Best said, in her experience, clinicians have been referring patients earlier for advanced therapies in recent years. Medication options have also improved over this period.

Dr Best referred to positive results from the EPSILON study, which investigated the efficacy of opicapone in enhancing the clinical benefit of levodopa in patients in earlier stages of PD, without end-of-dose motor fluctuations.

“Opicapone has been out on the market now for the past few years,” Dr Best told MI.

“And I suppose there has been some wariness around it; there certainly are some side-effects. But what we are seeing is that the trials are now showing that these newer drugs that are coming out are more beneficial.”

She also pointed out that foslevodopa-foscarbidopa was recently approved by the National Institute for Health and Care Excellence in the UK.

The medication is administered subcutaneously, preferably in the abdomen, avoiding a 5cm radius area from the navel.

“But it is also thinking about these other medications, these add-ons, other ways of delivery and avoiding the types of complications that come with late onstage PD.”

In addition, Dr Best said there have been notable developments in the delivery of deep-brain stimulation (DBS) over the past decade. “DBS has been around for about 30 years; it’s not new,” she told this newspaper.

“But what has happened, particularly over the past 10 years, is there has been a massive improvement in the software and in the nature of the leads themselves. So, it used to be your traditional lead just had four contacts and you just programmed off that. We now have multi-directional leads, so if the placement of the lead isn’t perfect, we can minimise the stimulation away and minimise side-effects. We are now moving into, I think the next big thing, which is adaptive neuro-stimulation.”

Appropriate patient selection for DBS is vital.

“Young patients do very, very well with DBS,” Dr Best said.

“There is an age restriction of course, usually around 70 – there can’t be any cognitive decline evident. So, they have to get a quite big work up before they come to DBS. But it is life changing. And I think we should be considering it more and we should be considering it earlier than we currently are and making more people eligible for it.”