Webinar with EURO-INF Project Leader Professor K Ray Chaudhuri discloses significant benefits of apomorphine and intrajejunal levodopa infusion in advanced Parkinson's disease.

25 June 2012

In an exclusive interactive webinar held on Wednesday 20th June at 14:30 BST, Professor K Ray Chaudhuri (King’s College Hospital, London and Clinical Director of the National  Parkinson Foundation), discussed the emerging and preliminary results of the ongoing EUROINF (1) comparative real life holistic (motor, non motor and quality of life) survey of  the effects of conventional therapies in advanced Parkinson’s disease. The survey is endorsed by the European patient group, EPDA and is currently being carried out across Europe in 8 countries. Central to this is the significant benefit seen with both apomorphine and intrajejunal levodopa infusion, on motor aspects of non motor symptoms (sleep, mood and fatigue) and overall quality of life (QOL) that mirrors the effects of deep brain stimulation (DBS), even in patients who would otherwise be unsuitable for  surgical therapy. Some improvements appeared to be specific for infusional therapies and while such data is as yet unavailable  for DBS therapy, the available evidence suggests that DBS may worsen issues such as restless legs syndrome and mood related symptoms. The survey also includes DBS cases for future comparative analysis. This survey was first presented and highlighted as a key contribution in the Movement Disorder Society's 16th International Congress of Parkinson's Disease and Movement  Disorders on Sunday June 17th.  

Professor Chaudhuri began by explaining the rationale behind the observational survey methodology and how it represented the best way to compare the two treatment strategies in real life scenarios. Focussing on patient QOL, the survey looked at the cumulative effects of both motor  and non motor symptoms, as non motor factors are widely recognised as having a primary impact on a patient’s QOL. While acknowledging that the survey is non-randomised,  something he believes would be almost impossible to conduct, he commented that it does represent, “a set of patients all GPs will have to deal with in real life.”  The survey also uses outcome measures that are “good guides to good clinical  practice … with validated motor and non motor scales in addition to validated measures of QOL.” The other strength of the survey lies in the numbers involved – over 40 patients on levodopa and 37 patients on apomorphine  – which makes it the largest cohort yet studied.  

When it comes to analysing the current results, while motor and non motor effects are appreciably affected by both therapies leading to a robust improvement in QOL there are subtle differences. One of the most noticeable of these is with reference to UPDRS III where both treatments work very well but where apomorphine in particular has a very strong effect on motor benefit. Professor Chaudhuri again, “Apomorphine also has an improvement on aspects of non  motor symptoms but perhaps not as good an effect on dyskinesia as one would expect.” This however may be because apomorphine was used concomitantly with oral treatment in most treatment centres.  Further investigation into specific non motor effects of both treatments is one direction that the survey is likely to take.  

A number of questions touched on the comparison between both treatments and deep brain stimulation. Professor  Chaudhuri notes that the evidence base for each had pro’s and con’s but asserted that a key consideration was the unsuitability of DBS for patients over a certain age or with certain cognitive issues. “So the real question arises, ‘what  do we offer these patients?’ In this situation apomorphine infusion as well as  levodopa infusion offers a valid treatment option, another therapeutic option which may be available. And in that sense, this piece of work has some real life  practical importance.”  

Professor Chaudhuri also commented on the need for all three treatments to ideally be made accessible to all patients based on informed choice. This is not the case in practice, for example, in the US, where deep brain stimulation remains the main pathway to advanced therapies while apomorphine infusion has not yet been licensed apart from in its intermittent injection form and levodopa infusion is still going through the licensing process. Only when patients and clinicians have access to all options can there be the best outcome for the patient.        

To watch the interview in full please visit http://microsites.streamuk.com/euroinf

1. The ‘real life’ observational study is the work of EUROPAR, an academic multi-disciplinary group  of movement disorders specialists, supported by the European Parkinson's  Disease Association and the PD Non Motor Group and is the largest cohort  study so far. Typically this involves a comparative look at the "infusion" therapies but will also be  extended to include deep brain stimulation of the subthalamic nucleus.  Furthermore, ‘old’ patients, usually excluded in clinical trials are included with the study also aiming to ‘audit’ a comparison of clinical practice across these centres.

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