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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Effective Management in Early Idiopathic Parkinson’s Disease


GOAL
To provide the target audience with up-to-date pratical information on the treatment and management of patients with early idiopathic Parkinson's disease.

TARGET AUDIENCE
This activity is designed for neurologists, movement disorder specialists, neuro-geriatric psychiatrists, and other professionals interested in Parkinson's disease (PD) or caring for patients with PD. No prerequisites required.

LEARNING OBJECTIVES
At the conclusion of this activity, the participant should be able to:

  • Identify patients with Parkinson's disease (PD) in need of early treatment.
  • Become familiar with the current treatment algorithms and medical considerations related to perceived degree of disability, individual needs, disease stage, and the age of the patient.
  • Distinguish disease progression from suboptimal treatment of PD.
  • Explain the role of the dopamine pathway in PD.
  • Discuss the pharmacology of dopaminergic drugs.
  • Describe the clinical application of nondopaminergic drugs and the practical advantages that they may offer in the management of PD in clinical practice.
  • Identify the benefits of continuous dopaminergic stimulation in order to improve patient quality of life.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide CME for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 2 hours. After reading this monograph, participants may receive credit by completing the CME test, evaluation, and receiving a score of 70% or higher.

Release date: December 15, 2008. Expiration date: December 15, 2010.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This activity is supported by an educational grant from UCB, Inc.

COURSE DIRECTOR

Zoltan Mari, MD
Assistant Professor
Department of Neurology
Johns Hopkins University
Baltimore, Maryland
Dr Mari reports having no relevant financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

Cynthia L. Comella, MD
Professor
Department of Neurological Sciences
Movement Disorders Section
Rush University Medical Center
Chicago, Illinois
Dr Comella reports receiving grants/research support from Allergan Inc, Boehringer Ingelheim, Ipsen Pharma, Merz Pharmaceuticals, and Solvay SA; and serving as a consultant for Boehringer Ingelheim, Impax Laboratories, Inc, Merz Pharmaceuticals, UCB, Inc, and Valeant Pharmaceuticals.

Daniel Tarsy, MD
Professor in Neurology
Harvard Medical School
Director, Parkinson's Disease and Movement Disorders Center
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Dr Tarsy reports having no relevant financial or advisory relationships with corporate organizations related to this activity.

Leo Verhagen Metman, MD, PhD
Associate Professor
Department of Neurological Sciences
Movement Disorders Section
Rush University Medical Center
Chicago, Illinois
Dr Verhagen Metman reports receiving grants/research support from Advanced Neuromodulation Systems, Inc, Allergan Inc, Bayer, Boothroyd Foundation, Ceregene, Inc, Merck & Co, Inc, Michael J. Fox Foundation, and the National Institutes of Health; serving as a consultant for Impax Laboratories, Inc and Medtronic, Inc; and serving on the speakers' bureau for UCB, Inc and Vernalis.

Notice: The audience is advised that an article in this CME activity contains reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Mari—domperidone.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Effective Management in Early Idiopathic Parkinson’s Disease
Zoltan Mari, MD*

Parkinson's disease (PD) is a chronic, progressive neuropsychiatric disorder and the second most common neurodegenerative disease after Alzheimer's disease.1 PD is a complex disorder, affecting a variety of dopaminergic and non-dopaminergic neural elements and pathways, and, as we have began to appreciate, it involves several seemingly unrelated non-motor features that may actually predate the manifestation of longer known motor features, such as tremor. The complexity of PD is observed in its pathology, presentation, progression, and response to treatment. There is no as-of-yet established biomarker for PD. "Hi-tech" imaging tools, such as positron emission tomography and single photon emission computed tomography imaging, are still used mostly for research purposes, and magnetic resonance imaging as well as other ancillary tests are generally ordered to rule out other possible causes of parkinsonian symptoms. Diagnostic criteria for PD have been proposed and agreed upon, but these criteria remain clinical and subjective, thus subject to error. In fact, it is not uncommon for a diagnosis to take several years of watchful waiting, before the diagnostic confidence can reach 90% (a level sometimes used as a criterion for enrolling in clinical trials – although a lower degree of confidence is usually satisfactory for clinical management purposes) or for a PD diagnosis to be reversed as new signs, symptoms, or unexpected treatment responses emerge. As an example, Caslake et al report that the clinical diagnosis of certain types of parkinsonism changed in 33% of 82 incident patients after 29 months of follow-up.2

Despite the rapidly growing scientific literature on PD and the available guidelines and practice parameters, navigating through the therapeutic choices in early PD management remains challenging to most physicians.

This issue of Johns Hopkins Advanced Studies in Medicine is based on a symposium that was held in Salt Lake City, Utah, on September 19, 2008. The symposium faculty included in our presentations video excerpts of interviews with our own patients with PD and our conduction of a directed neurologic examination on these patients, to illustrate the main challenges that are encountered during diagnosis and management of PD in its early stages. Based on audience feedback, this was an effective learning tool for clinicians who regularly treat or have an interest in movement disorders.

For this monograph, the challenge was to effectively convey the same teaching points in a non-visual medium. Book chapters, courses, publications, and other media products have been and continue to be created with somewhat similar goals of addressing the challenges in early PD management.3,4 This monograph aims to provide a focused and pragmatic overview of the main challenges clinicians encounter while managing patients with early PD. Leo Verhagen Metman, MD, PhD, reviews the challenges of diagnosis of early PD, including non-motor features and the role of patient history based on a case interview provided by Cynthia L. Comella, MD. As Dr Verhagen Metman explains, the patient's own words will often tell the physician the diagnosis if a careful history is taken. Dr Verhagen Metman also reviews PD pathology and nonpharmacologic therapies for PD. As we learned from Dr Verhagen Metman, pathological changes in PD begin developing years before they lead to the appearance of motor and non-motor symptoms. The appearance and chronology of seemingly unrelated symptoms do reveal a striking correlation with the chronology and topology of specific PD pathological findings, as described by Braak et al.5 As reviewed by Dr Verhagen Metman, nonpharmacologic treatment options are often considered in initial PD management even before starting medications. Next, Daniel Tarsy, MD, discusses the common challenges in determining when to initiate pharmacologic treatment and how to best assess treatment response. My article continues this review of assessing treatment response and treatment options with a discussion of when and how to change the initial treatment. As all 3 of us note, treatment plans must be individualized for each patient with PD because each patient has his or her own definition of disability, tolerance for side effects, willingness to pursue nonpharmacologic treatments, and patient-physician treatment strategy, among other factors. Some of the key points of early PD management were discussed in more than one presentation, which helped the educational experience by providing focus and proper emphasis, as well as allowed review of different aspects of these key points by different faculty members. Based on this successful course, it is our hope that the information presented in this monograph will help clinicians navigate through the challenges of diagnosing and managing early PD.

REFERENCES

1. Alves G, Forsaa EB, Pedersen KF, et al. Epidemiology of Parkinson's disease. J Neuro1. 2008;255(suppl 5):18-32.
2. Caslake R, Moore JN, Gordon JC, et al. Changes in diagnosis with follow-up in an incident cohort of patients with parkinsonism. J Neurol Neurosurg Psychiatry. 2008;79:1202-1207.
3. Jankovic J. Parkinson's disease: clinical features and diagnosis. J Neurol Neurosurg Psychiatry. 2008;79:368-376.
4. Weiner WJ. Early diagnosis of Parkinson's disease and initiation of treatment. Rev Neurol Dis. 2008;5:46-53.
5. Braak H, Del Tredici K, Rub U, et al. Staging of brain pathology related to sporadic Parkinson's disease. Neurobiol Aging. 2003;24:197-211.

*Assistant Professor, Department of Neurology, Johns Hopkins University, Baltimore, Maryland.

Address correspondence to: Zoltan Mari, MD, Assistant Professor, Department of Neurology, Johns Hopkins University, 600 North Wolfe Street, Meyer 6-119B, Baltimore, MD 21287. E-mail: zmari1@jhmi.edu.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his or her article and all its contents.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.