Non-oral therapy roadshows and the relevance of the NICE guidelines for Parkinson’s

by Dr Christopher KobyleckiNon-oral therapies for Parkinson’s disease comprise apomorphine infusion, deep brain stimulation (DBS) surgery, and levodopa-carbidopa intestinal gel (LCIG, Duodopa®). Whereas people with Parkinson’s disease typically respond consistently to oral medications for several years, motor fluctuations and levodopa-induced dyskinesia affect half of patients after 4-5 years (1). This heralds the “complex” phase of Parkinson’s, where oral medications can no longer adequately control motor complications. The presence of such motor complications despite the use of five or more levodopa doses per day with adjunctive oral therapies usually indicates the possibility the patient may require consideration of non-oral therapies. There is evidence for inequality of opportunity of people with Parkinson’s to be considered for non-oral therapy (2). This suggests that improving awareness of the indications and use of non-oral therapies could improve referral rates and ensure better uptake in those who could potentially benefit from such treatments.It was a pleasure to be involved for the second time in delivering the Non-Oral therapy Roadshow in Manchester this year. Setting the scene for the roadshow, Dr Jason Raw, our local Parkinson’s Excellence Network lead described the scale of the problem and the nature of motor fluctuations. This was followed by an overview of the different non-oral therapies and their mechanisms. My PD nurse specialist colleagues Patsy Cotton and Lucy Partington-Smith then delivered an overview of the practicalities of treatment with apomorphine, DBS and LCIG with particular reference to how this is initiated and delivered locally in Manchester. Sue Thomas discussed the use of data to improve PD services, and the meeting finished with an interactive discussion of real-life cases referred for non-oral therapies.The roadshow generated interesting discussion about the criteria for considering specific therapies in different cases. How we define the “complex” phase and the importance of intervening at the right time is key to better understanding of how such therapies are used, and we spent some time going over this. The use of wearable technology such as the Parkinson’s Kinetigraph (PKG) in patient selection and assessment of the effectiveness of therapies was also discussed (3). Case presentations from everyday practice are always useful in getting these points across and generated some lively discussion. One key point that emerged is that there is no “one size fits all” approach to non-oral therapies. Careful consideration of factors including patient expectations, non-motor symptom burden, comorbid conditions and neuropsychiatric symptoms is key to ensuring the right treatment selection and patient benefit.This was the first Non-Oral Therapy Roadshow following the latest iteration of the NICE guidelines for Parkinson’s disease, published in July 2017 (4). We were therefore able to discuss where these therapies fit in to the NICE guidelines, which state:

• “Offer people with advanced [which equates to “complex”] Parkinson’s disease best medical therapy, which may include apomorphine”. This supports the use of apomorphine in the management of complex PD as represented at the roadshow and per the non-oral therapy pathway.
• “Do not offer DBS to people with Parkinson’s disease whose symptoms are adequately controlled by best medical therapy”. We discussed how to define “adequate control” and that this may be difficult to clarify just from history taking, so the use of wearable devices has helped us identify more potential candidates for non-oral therapies.
• “Consider DBS for people with advanced [“complex”] Parkinson’s disease whose symptoms are not adequately controlled with best medical therapy”. We discussed at the roadshow the criteria for considering DBS and other non-oral therapies, the MDT assessment process as well as what symptoms are more likely to respond or be exacerbated by specific therapies.
• The guidelines state that “LCIG is available through NHS England commissioning policy”, and that “if DBS and LCIG were both options, then DBS should be preferred to LCIG”. We discussed this at the roadshow and emphasized that DBS is usually the preferred option in our and in most other centres, but that a minority of patients are not able to have DBS and for these, LCIG represents a safe and effective treatment.

Overall the NICE guidelines support our existing framework for the use of non-oral therapies and we hope to improve the awareness and uptake of these vital treatments in people with Parkinson’s across Greater Manchester.Find out more about the Non-Oral Therapy Roadshow - course dates for 2018 are still to be confirmed.

References

1. Ahlskog JE, Muenter MD. Frequency of levodopa-related dyskinesias and motor fluctuations as estimated from the cumulative literature. Mov Disord 2001;16(3):448-58.
2. Lokk J. Lack of information and access to advanced treatment for Parkinson's disease patients. J Multidiscip Healthc. 2011;4:433-9.
3. Horne MK, McGregor S, Bergquist F. An objective fluctuation score for Parkinson's disease. PLoS One. 2015;10(4):e0124522.
4. National Institute for Health and Care Excellence. Parkinson's disease in adults: diagnosis and management. 2017.

Dr Christopher Kobylecki is Consultant Neurologist at Greater Manchester Neurosciences Centre, Salford