Dr Stewart Factor Discusses Management of OFF Periods, Treatment Innovations in Parkinson Disease

The addition of Kynmobi, a discreet, under the tongue treatment of OFF periods in patients with Parkinson disease, adds to the growing market of innovations in care, said Stewart Factor, DO, professor of Neurology and director of the Movement Disorders Program at the Emory University School of Medicine.

The addition of Kynmobi, a discreet, under the tongue treatment of OFF periods in patients with Parkinson disease, adds to the growing market of innovations seeking to individualize patient care, said Stewart Factor, DO, professor of Neurology and director of the Movement Disorders Program at the Emory University School of Medicine.


AJMC®: Hello, I'm Matthew Gavidia. Today on MJH Life Sciences News Network, The American Journal of Managed Care® is pleased to welcome Dr Stewart Factor, professor of Neurology and director of the Movement Disorders Program at the Emory University School of Medicine. What significance may the dissolvable aspect of Kynmobi have for those with PD?

Dr Factor: Kynmobi is an on-demand therapy that you take when you're starting to feel like your OFF time is coming, and to control you for several hours and fill that gap. The other available drugs out there are the injectable form of apomorphine and the inhaled form of levodopa that just came out last summer. So, I think 1 of the benefits of Kynmobi is that you just take the film and you put it under your tongue, there's no mechanism related to using it. So, there's an ease of use there that I think will be beneficial to patients, especially those advanced Parkinson patients who really have trouble manipulating an injector or even manipulating an inhaler.

So, I think that aspect of it will be very helpful and easier for patients. It's absorbed very quickly, and it has a rapid time of onset. At 15 minutes, when we were examining people in the office, we were already seeing a pretty substantial benefit in patients. So, it works much faster than the oral medications also. So, I think that's where the dissolvable piece of it is helpful.

AJMC®: In your experience, how have you managed the care of patients with PD experiencing OFF periods? And what requests do you typically have from patients?

Dr Factor: Oh, well, the requests are that they have these OFF periods, and that whether predictable or unpredictable, the timing of their meds just is not adequately helping them for that and that they interfere with their daily function, whether in a minor way or a major way. So, the way of addressing this is, there are sort of 4 directions now that people can go in treating this.

So, we have adjunctive medicines that they can take with their levodopa. These are medicines that either enhance the duration of effective levodopa—so, there are 2 forms of long acting levodopa that are available or there are drugs, they're called COMT inhibitors that enhance the absorption of the levodopa to make it last longer. There are MAO inhibitors that decrease the metabolism of dopamine in the brain to make the dopamine within the brain that's already there stay around longer. Then there are dopamine agonists, which stimulate specific dopamine receptors, and all have much longer half-life. So, you can utilize those as an adjunct to try and prevent the OFF times or diminish them by providing them with regular oral dosing–1 of the dopamine agonists actually is a patch. So, that can be helpful. So, that's 1 strategy of treating those.

Another strategy is infusions. So, there is a levodopa gel that can be infused directly into the gastric tract into the duodenum. It's done with a feeding tube, a PJ tongue we call it. So, they carry a pump around, and they get a continuous flow of this levodopa gel to try to do away with the ups and downs that people are having in their blood levels. So that's a second way of handling it.

The third is the on-demand drugs, the injectable apomorphine, inhaled levodopa, and now the sublingual apomorphine. So, that's another option where instead of regularly taking higher doses all day long, they can just target the regions or the times when they're having these.

Then the final choice is surgery, which is deep brain stimulation surgery where they get electrodes placed into their brain to alter the firing patterns in the deep regions of the brain.

AJMC®: What further innovations or trials within treatment of OFF periods are you monitoring?

Dr Factor: So, 1 that's very interesting is gene therapy, where they actually will inject into the brain a virus that carries the DNA for a gene or an enzyme that enhances the metabolism of levodopa to dopamine, so that more of the levodopa getting into the brain gets converted, and it's more continuous. So, it would help to sort of reverse the onset of these OFF times and improve the utilization of the drugs within the brain itself. So that's 1 that's already being tested in patients and clinical trials. There are other gene therapies, not just that 1, but there are combined multi gene trials and several other types that are being utilized. It's really a great, interesting technology that's available.

I think there was something in the news this week or last week, and I haven't actually read the details of it, but stem cells are coming back into the picture and they're going to be looked at. I know there are several tech companies that are developing stem cells from patients' own skin cells. So, they take the skin cells, and they engineer them to become dopaminergic neurons, and then several months later, they can inject them into the brain in order to treat fluctuating patients to see if it kind of improves that.

So, those are some of the things. I think the deep brain stimulation—there's a lot of technological changes that are that are occurring as well. So, there are a number of very interesting things. There's also subcutaneous infusions instead of putting a feeding tube in, you can do an infusion just under the skin. There's an apomorphine study that's ongoing, and there's a levodopa study that's ongoing as well.

AJMC®: Lastly, is there anything else you wanted to talk about that has not yet been addressed?

Dr Factor: No, I just think this is a very exciting time for Parkinson patients and the addition of new drugs like Kynmobi providing more choices for patients actually will help improve quality of life for at least some patients with PD. The more choices we have, as I told you, we now have numerous choices for treating OFF times. As those choices increase, there's more of an opportunity to find the right treatment for individual patients to help their function and to allow them to have better quality of life long-term. So, that to me is the big opportunity that we're seeing with the approval of several new drugs and the development of new technologies.

AJMC®: To learn more, visit our website at I'm Matthew Gavidia. Thanks for joining us!

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