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Advanced Parkinson's disease is characterized by motor and non-motor fluctuations to oral dopamine replacement therapy. The BALANCE study evaluated the clinical practice in Germany and Switzerland, when patients eligible for levodopa/carbidopa intestinal gel (LCIG) therapy decided to either switch to LCIG or to stay on optimized standard of care (SoC) oral therapy as a non-randomized regular clinical decision.In this non-interventional, multicenter, prospective observational study, patients were recruited between 2015 and 2020. We obtained comprehensive baseline characteristics in both groups. As primary endpoint, we evaluated whether LCIG led to higher quality-of-life (QoL) improvement than SoC after 12 months. As secondary endpoints, we studied several motor and non-motor outcomes.About half of the 137 patients decided for LCIG treatment (n = 73, 53.5%). Those were agedgt;70 years more often, had more advanced disease stage, higher burden of motor and neuropsychiatric symptoms, and cognitive impairment including dementia compared to SoC. QoL change after 12 months did not differ between groups (P = 0.286). The LCIG group improved in secondary outcomes, including the UPDRS III in ON, UPDRS IV, Unified Dyskinesia Rating Scale, and Non-Motor Symptoms Scale. Clinical Global Impression-Improvement scale improved in 78.0% and 19.5% of patients receiving LCIG and SoC, respectively. Caregiver burden remained stable in LCIG but worsened with SoC.In current practice, patients and physicians delayed LCIG treatment and started substantially beyond the established indication criteria. This practice bears the risk to produce inferior results compared to the results from existing high-level evidence.

Introduction ND0612 is a continuous, subcutaneous levodopa/carbidopa delivery system under development for patients with Parkinson's disease (PD) and motor fluctuations. Methods This was a randomized, placebo-controlled, double-blind, 2-period study evaluating the safety and pharmacokinetics of ND0612 in PD patients on an optimized oral levodopa regimen and experiencing ≥2 h/day of OFF time. During Period-1, patients received their current standard of care (SoC) levodopa/carbidopa and were randomized (2:1) to 14 days treatment with adjunct ND0612 (daily levodopa/carbidopa dose of 270/63 mg) or placebo infusion +SoC. During Period-2, 16 patients were randomized to receive 7 days treatment with ND0612 or ND0612 plus oral entacapone. Reduction in OFF time was analyzed as an exploratory measure using a futility design with a predefined margin of 1.6 h. Results ND0612 was well-tolerated; most patients experienced infusion site nodules (95% vs. 56% with placebo), which all resolved without sequelae. Patients treated with adjunct ND0612 during Period-1 avoided deep troughs in levodopa plasma levels and had a decreased fluctuation index versus placebo (1.6 ± 0.5 vs 3.1 ± 1.6 at end of Period-1, respectively). In Period-2, the coadministration of entacapone with continuous ND0612 SC infusion translated to an increase in mean levodopa AUC0–10h compared to baseline. Exploratory efficacy analysis of Period 1 showed mean ± SD OFF time reductions of −2.13 ± 2.24 [90%CI: -2.8, ∞] hours (p = 0.84 using H0 of μ0 ≤-1.6). Conclusion Levodopa/carbidopa infusion with ND0612 was generally well-tolerated and resulted in reduced fluctuations in plasma levodopa concentrations when given with SoC oral levodopa. ND0612 met the efficacy endpoint for the futility design.

BACKGROUND Levodopa-carbidopa intestinal gel (LCIG) is an advanced therapy for patients with Parkinson Disease (PD). Weight loss has been pointed out as an adverse event of LCIG infusion. AIMS OF THE STUDY To compare weight changes between three groups of PD patients: patients treated with LCIG, patients within the first year of subthalamic deep brain stimulation (STN-DBS) and patients treated exclusively with oral treatment during 1 year of follow up. METHODS Patients treated with LCIG were retrospectively matched by age, gender, disease duration and Hoehn and Yahr to patients undergoing STN-DBS and to patients both receiving the standard of care treatment and unwilling advanced therapies (SOC). Clinical features and weight were collected at baseline, and 12 months after introducing the treatment (LCIG and STN-DBS groups) or for one year of treatment (SOC). RESULTS Eighteen patients were included in each group. They had no differences in clinical and demographic features, except for cognitive impairment. There was a mean weight (-5.8kg ±6.8) and BMI (-2.1kg/m2±2.6) reduction in the LCIG group after 12 months, while there was a slight weight loss in the SOC (-1.4kg ±3.1) and a weight increase in the STN-DBS group (5.4kg ±4.7). Differences of weight were statistically different between, LCIG and STN-DBS (P

The use of catechol-O-methyltransferase inhibitors may mask doping agents, primarily levodopa, administered to racehorses and prolong the stimulating effects of dopaminergic compounds such as dopamine. It is known that 3-methoxytyramine is a metabolite of dopamine and 3-methoxytyrosine is a metabolite of levodopa thus these compounds are proposed to be potential biomarkers of interest. Previous research established a urinary threshold of 4,000 ng/mL for 3-methoxytyramine to monitor misuse of dopaminergic agents. However, there is no equivalent biomarker in plasma. To address this deficiency a rapid protein precipitation method was developed and validated to isolate target compounds from 100 µL equine plasma. A liquid chromatography-high resolution accurate mass (LC-HRAM) method using an IMTAKT Intrada amino acid column provided quantitative analysis of 3-methoxytyrosine (3-MTyr) with lower limit of quantification of 5 ng/mL. Reference population profiling (n = 1129) investigated the expected basal concentrations for raceday samples from equine athletes and showed a right-skewed distribution (skewness = 2.39, kurtosis = 10.65) which resulted from large variation (RSD = 71%) within the data. Logarithmic transformation of the data provided a normal distribution (skewness = 0.26, kurtosis = 3.23) resulting in the proposal of a conservative threshold for plasma 3-MTyr of 1,000 ng/mL at a 99.995% confidence level. A 12-horse administration study of Stalevo® (800 mg L-DOPA, 200 mg carbidopa, 1600 mg entacapone) revealed elevated 3-MTyr concentrations for 24-hours post-administration.

Percutaneous endoscopic gastrostomy (PEG) is required for Levodopa/Carbidopa Intestinal Gel (LCIG) delivery in patients with advanced Parkinson's disease (PD) as well as for enteral feeding in a variety of neurological disorders. Buried Bumper Syndrome (BBS) is a serious complication of PEG. The frequency of BBS in patients receiving LCIG treatment has never been reported.To compare the frequency of BBS in patients on LCIG treatment or on enteral feeding over the past 12 years and identify possible risk factors.We reviewed prospectively recorded data from 2009 to 2020 on two case-series: LCIG-treated PD patients and non-PD patients on enteral nutrition. We identified all BBS incidences. Patients' characteristics, clinical manifestations, BBS management, possible risk factors and outcomes were analyzed.During the 12 years, 35 PD patients underwent PEG insertion for LCIG infusion, and 123 non-PD patients for nutritional support. There were eight cases of BBS in six PD patients (17.1%). Six of them were effectively managed without treatment discontinuation. Of the enteral feeding patients, only one developed BBS (0.8%) (p 0.001). We identified inappropriate PEG site aftercare, weight gain, early onset PD, longer survival, treatment duration, dementia and PEG system design as potential risk factors for BBS development.BBS occurs more frequently in LCIG patients than in patients receiving enteral feeding. If detected early, it can be successfully managed, and serious sequalae or treatment discontinuation can be avoided. Regular endoscopic follow-up visits of LCIG-treated patients and increased awareness in patients and clinicians are recommended.

Parkinson's disease is associated with a variety of dermatologic disorders and the study of skin may provide insights into pathophysiological mechanisms underlying this common neurodegenerative disorder. Skin disorders in patients with Parkinson's disease can be divided into two major groups: 1) non-iatrogenic disorders, including melanoma, seborrheic dermatitis, sweating disorders, bullous pemphigoid, and rosacea, and 2) iatrogenic disorders related either to systemic side effects of antiparkinsonian medications or to the delivery system of antiparkinsonian therapy, including primarily carbidopa/levodopa, rotigotine and other dopamine agonists, amantadine, catechol-O-methyl transferase inhibitors, subcutaneous apomorphine, levodopa/carbidopa intestinal gel, and deep brain stimulation. Recent advances in our understanding of the role of α-synuclein in peripheral tissues, including the skin, and research based on induced pluripotent stem cells derived from skin fibroblasts have made skin an important target for the study of Parkinson's disease pathogenesis, drug discovery, novel stem cell therapies, and diagnostics.

Herein, to monitor the concentration of carbidopa in an aqueous solution, an analytical approach based on electrode surface modification by Pt/SWCNTs as a sensor has been proposed. Pt/SWCNTs was synthesized by polyol strategy and characterized by the TEM method. Results confirmed spherical Pt nanoparticles with a diameter of about 10 nm decorated at the surface of SWCNTs with good distribution. The carbon paste electrode modified (CPEM) with Pt/SWCNTs was fabricated by mixing 12% of nanocomposite as an optimum condition with graphite powder in the presence of paraffin oil as a binder. Carbidopa's oxidation signal was enhanced by about 2.73 times when using the CPEM/Pt/SWCNTs, and its oxidation potential was decreased by about 110 mV. Additionally, the sensor demonstrated a linear dynamic range of 1.0 nM-120 M with a detection limit of 0.5 nM at pH = 7.0 as the ideal condition for monitoring carbidopa. Therefore, carbidopa in water and dextrose saline can be detected using CPEM/Pt/SWCNTs with an acceptable recovery range.

Introduction CVT-301 (Inbrija®) is a levodopa inhalation powder for on-demand treatment of OFF episodes in Parkinson's disease patients treated with carbidopa/levodopa. Safety and efficacy results of a 12-month, dose-level blinded extension study of a phase 3 trial (SPAN℠-PD) of CVT-301 are presented. Methods Patients were receiving oral carbidopa/levodopa and adjunctive CVT-301 treatment, blinded to dose (60 mg or 84 mg, N = 325). Study visits occurred every 3 months. Pulmonary function was assessed by spirometry. Other safety assessments included dyskinesia and adverse events (AEs). Secondary objectives of the study included maintenance of improvement assessments for occurrence of an ON state during the 60-min post-dose period, change in total daily OFF time, and Patient Global Impression of Change (PGIC). Results Most frequent AEs (≥5%) were cough (15.4%), fall (13.1%), upper respiratory tract infection (7.1%), and dyskinesia (5.1%). Severe AEs (>1 event) were cough (1.9%) and dyskinesia (0.6%). Twelve-month mean changes from baseline for FEV1, FVC, and DLCO were −0.092 L, −0.097 L, and −0.922 mL/min/mmHg, respectively. At 12 months, 73.0% of patients on 84 mg achieved an ON state within 60 min. Total daily OFF time was reduced by 0.55 h (month 1) and 0.88 h (month 12) for the 84 mg dose. Percentage of patients self-reported as improved by PGIC was 65.5–91.9% over 12 months. Conclusion CVT-301 was generally well-tolerated. Twelve-month decline in pulmonary function was consistent with a prior PD control group. Exploratory efficacy results showed CVT-301 maintained improvement at achieving ON states in patients experiencing OFF episodes, decreasing daily OFF time, and maintaining improvement in PGIC.

Introduction The efficacy and safety of apomorphine sublingual film (APL-130277; APL) for the on-demand treatment of “OFF” episodes associated with Parkinson's disease (PD) was demonstrated in a double-blind trial. Herein we describe the ability of patients to receive effective and tolerable APL dose titration during the open-label titration phase. Methods Adult patients with levodopa-responsive PD and “OFF” episodes were enrolled. In practically defined “OFF,” patients were observed for a FULL “ON” after their usual morning carbidopa/levodopa (CD/LD) dose and then after titration with APL following each increasing dose (10–35 mg). Antiemetic medication was administered for 3 days before initiation of titration and was continued throughout titration. Motor responses were evaluated predose and postdose using Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) Part III score. Safety outcomes were evaluated. Results Among 141 patients who enrolled in the study and received APL during open-label titration, 109 (77.3%) achieved a FULL “ON” (66.1% at 10–20 mg) and 10 did not. Patients who successfully completed APL dose titration tended to be younger, had a longer mean time since PD diagnosis, and had lower levodopa requirements than those who discontinued during titration for any reason. Change in MDS-UPDRS Part III scores from predose to 30 min postdose after titration with the effective dose of APL (n = 109) was similar across all dose groups. In a post hoc analysis, the magnitude of motor response with APL was ~2-fold higher than with CD/LD 15 min postdose, and the observed peak response occurred earlier with APL than with the trend seen for CD/LD (45 vs 90 min, respectively). Overall, the most common (≥10%) treatment-emergent adverse events (TEAEs) during APL dose titration were nausea (20.6%), yawning (12.1%), dizziness (11.3%), and somnolence (11.3%). Twelve patients discontinued due to TEAEs during APL dose titration, most commonly (≥2%) because of dizziness (2.8%), nausea (2.1%), and somnolence (2.1%). Conclusion Among eligible patients with PD and “OFF” episodes who had their APL dose successfully titrated to an effective and tolerable level, most were able to do so within the first 3 titrated doses but some required further dose escalations. The use of APL can provide benefit for the treatment of “OFF” episodes.

Introduction There is considerable intra- and inter-individual variability in the pharmacokinetics (PK) of levodopa after oral administration. Inter-individual variability in levodopa PK has also been demonstrated in fasting single-dose studies. We examined the factors that affect levodopa PK in patients with Parkinson's disease (PD) and quantified the intensity of their respective effects. Methods We studied 220 patients who underwent PK assessment after administration of 1 tablet of levodopa/DOPA decarboxylase inhibitor (DCI) combination, which contained 10 mg carbidopa/100 mg levodopa or 25 mg benserazide/100 mg levodopa. PK was evaluated using non-compartmental analysis. Results In total, 220 PD patients (including 112 men) were studied. The mean age (±standard deviation) and mean disease duration was 68.1 ± 8.9 and 7.7 ± 5.8 years, respectively. The Cmax of levodopa was 9.0 ± 4.0 ng/mL, Tmax was 41.4 ± 40.2 min, and area under the blood concentration–time curve up to 4 h (AUC4hr) was 12.3 ± 3.7 ng/mL*4hr. Factors affecting AUC4hr were analyzed using multiple linear regression models. Age (1.1 ± 0.23 per +10 years, p = 3.1E-8), sex (2.2 ± 0.5 for female, p = 1.9E-5), DCI (1.4 ± 0.4 for benserazide, p = 0.0028), and body weight (−0.77 ± 0.22 per +10 kg, p = 5.4E-4) were significantly related to AUC4hr, while disease duration, dyskinesia status, and eGFR were not related to AUC4hr and Cmax. Conclusion Female, aging, difference formulations of DCI, or lower body weight independently contributes to increased AUC4hr of levodopa in Japanese patients with PD in this study.

Background Declining function in dopamine circuits is implicated in normal aging and late-life depression (LLD). Dopamine augmentation recently has shown therapeutic promise, but predictors of response are unknown. Methods Depressed elders with slowed gait underwent baseline magnetic resonance imaging (MRI) and [11C]raclopride positron emission tomography (PET). Subjects then received open treatment with carbidopa/levodopa (L-DOPA) for three weeks. Linear regressions examined relationships between baseline MRI measures, [11C]raclopride binding, and behavioral outcomes. Results Among N = 16 participants aged 72.5 ± 6.8 years, higher left superior temporal gyrus volume was associated with higher processing speed at baseline, while cortical thinning in a processing speed network was associated with greater improvement following L-DOPA. Greater volume and cortical thickness in brain regions associated with mobility were associated with higher baseline gait speed. Higher baseline white matter hyperintensity volume predicted less post-L-DOPA improvement on dual task gait speed and IDS-SR scores. Higher [11C]raclopride binding in the associative striatum was associated with cortical thickness in some, but not all, processing speed brain regions, while higher binding in sensorimotor striatum was significantly associated with left caudate volume. Limitations Limiting the conclusions drawn from this pilot study are the small sample size and open administration of L-DOPA. Conclusions Greater baseline brain volumes and cortical thickness in regions supporting cognition and gait were associated with higher behavioral performance, while lower structural integrity was associated with increased responsivity to L-DOPA. If substantiated in larger studies, these findings could facilitate the targeting of dopaminergic treatments to those LLD patients most likely to respond.

A unique challenge in some brain tumor patients is the fact that tumors arising in certain areas of the brain involve the neural structures of consciousness or alertness, limiting the patient’s ability to participate in rehabilitation following surgery. A critical question is whether neurostimulant therapy can help patients participate in rehabilitation efforts. We performed a retrospective review of all patients undergoing brain tumor surgery by the senior author from 2012 to 2018. We limited this study to patients with tumors occupying critical structures related to consciousness, alertness, and motor initiation. A combination of methylphenidate and levodopa/carbidopa was used to monitor the progress of patients through neurorehabilitation efforts. We identified 101 patients who experienced an inability to participate in rehabilitation (ITPR) in the post-operative period. Of these, 86 patients (85%) were treated with methylphenidate and levodopa/carbidopa. Cases of ITPR were related to dysfunction of the brainstem (12/86 cases, 14%), thalamus (17/86 cases, 20%), hypothalamus (14/86 cases, 16%), basal ganglia (13/86 cases, 15%), and medial frontal lobe (30/86 cases, 35%). Of the 86 individuals treated, 47/86 patients (55%) showed early improvement in their ability to participate with rehabilitation. At three month follow-up, 58/86 patients (67%) had returned to living independently or were at least interactive and cooperative during follow-up examination. This feasibility report suggests that combined therapy with methylphenidate and levodopa/carbidopa may help patients participate in neurorehabilitation efforts in the immediate post-operative period following brain tumor surgery. Randomized, controlled clinical trials are needed to explore this concept more thoroughly.

Background Levodopa-carbidopa intestinal infusion is an effective treatment for motor fluctuations in Parkinson's disease. However, it has been recently associated with emergent complex/atypical dyskinesias. We sought to characterize patients who developed these dyskinesias after levodopa infusion initiation, and to compare these patients to a control population with conventional motor fluctuations. Methods 208 Parkinson's disease patients, treated with levodopa intestinal infusion due to motor fluctuations, were screened for onset and/or worsening of dyskinesias after initiation of levodopa infusion, resistant to the routine titration, and presenting with atypical or unexpected patterns. Patients with extensive follow-up data were enrolled for a longitudinal analysis. Cases were compared to a control sample with conventional motor fluctuations in order to investigate predisposing factors, difference in dyskinesia phenotype, management strategies and dropouts. Results Thirty patients out of 208 (14.4%) reported atypical (i.e. long-lasting) biphasic, biphasic-like (i.e. continuous) or mixed (peak-dose and continuous biphasic) dyskinesias after levodopa infusion. They were compared at baseline and follow-up to a sample of 49 patients with conventional motor fluctuations on levodopa infusion. Both groups had similar demographic and clinical features, except the former having higher prevalence of biphasic dyskinesias while on oral therapy. Biphasic-like dyskinesias in nearly half the number of cases improved with increasing the dopaminergic load, while mixed dyskinesias had the worst outcome and highest dropout rate (58%). Conclusions Atypical biphasic, biphasic-like and complex dyskinesias could hinder the course of patients treated with levodopa infusion. This study further informs the selection process of advanced therapies, particularly in dyskinetic patients.

In this study, a UV-vis spectrophotometric method coupled with net analyte signal (NAS) and principal component regression (PCR) as multivariate calibration methods were used for the simultaneous determination of levodopa (LEV) and carbidopa (CBD) in prepared mixtures, pharmaceutical formulation, and breast milk sample. The mean recovery of the NAS model was 98.10% and 99.60% for LEV and CBD, respectively. Also, the relative standard deviation (RSD%) values were found to be lower than 5.5% and 4% for LEV and CBD, respectively. On the other hand, the mean recovery of LEV and CBD related to the PCR method was obtained at 96.86% and 92.43%, respectively. K-Fold cross-validation was used to estimate the number of components, which was 7 and 3 with a mean square error prediction (MSEP) of 1.50 and 7.14 for LEV and CBD, respectively. The results revealed that the NAS model was better than the PCR model. Additionally, the proposed NAS-based calibration method was successfully developed for the simultaneous analyses of LEV and CBD in a commercial tablet and breast milk.

Parkinson's disease is the second most prevalent neurodegenerative disease after Alzheimer's disease, mostly happened in the elder population and the prevalence gradually increased with age. Parkinson's disease is a movement disorder that severely affects patients' daily life. The mechanism of Parkinson's disease still remains unknown, however, studies already proved that the damage or absence of dopaminergic neurons located in the substantia nigra and the decreased dopamine in the striatum are significantly related to Parkinson's disease. To date, the mainstream treatment of Parkinson's disease has been achieved by alleviating its associated morbid symptoms, such as the use of levodopa, carbidopa, dopamine receptor agonists, monoamine oxidase type B inhibitors, anticholinergic drugs, etc. However, strong side effects, even toxicity, have been reported after using these drugs, with reduced effectiveness over time. Plant compounds have shown good therapeutic effects in neurodegenerative diseases as a less toxic treatment. In this review, we have compiled several natural plant compounds and classified the currently reported compounds for therapeutic use based on their structural parent nuclei and constituent elements. We wish to inspire new ideas for the treatment of Parkinson's disease by summarizing their mechanisms.

An electrochemical sensor using three dimensional (3D) cloves bud like gadolinium doped ZnO nanoflowers strewn reduced graphene oxide (GZO@rGO) modified glassy carbon electrode was proposed for the sensitive and selective detection of l-dopa. The GZO@rGO nanocomposite was synthesized by hydrothermal method and characterized by a variety of analytical and spectroscopy techniques, viz. Field Emission Scanning Electron Microscopy, X-Ray Diffraction, Fourier Transformed Infrared Spectrum and X-ray photoelectron spectroscopy. The electrochemical characterization was evaluated by Cyclic Voltammetry (CV), Electrochemical Impedance Spectroscopy (EIS) and Differential Pulse Voltammetry (DPV). The 3D cloves bud like GZO@rGO hybrid displayed the highest electro-catalytic behaviour for the selective l-dopa detection. Under optimum conditions, the oxidation current response of l-dopa is directly proportional to its concentration ranging from 10 to 100 nM. The sensitivity and limit of detection was calculated as 0.1 μA nM−1 cm-2 and 0.82 nM respectively. Moreover, the proposed electrode offers excellent selectivity, because it can efficiently evade the intervention of carbidopa and ascorbic acid even in the higher concentration. Thus, the reported sensor exhibits accurate determination of l-dopa (in the presence of carbidopa & ascorbic acid) and possesses an excellent real-time application with Mucuna prurita, pharmaceutical and human urine samples.

Introduction Dopamine replacement via levodopa (LD) remains the most effective treatment for Parkinson's disease (PD), yet its use is often associated with motor complications within several years of continued use. The Accordion Pill® (AP-CD/LD) is a novel drug delivery system based on gastric retention of multilayer films containing immediate-release (IR) carbidopa (CD) and immediate- and controlled-release LD. The AP-CD/LD was designed to improve the consistency of LD in the bloodstream while offering patients with PD more consistent symptom management. Methods This phase 2, multicenter, open-label, two-way randomized crossover study included 4 cohorts of participants with PD, each receiving AP-CD/LD (50/250 mg, 50/375 mg or 50/500 mg) twice daily in one treatment period and an active comparator in the other treatment period. Pharmacokinetics (PK) and efficacy were evaluated for AP-CD/LD vs IR-CD/LD. Treatment-emergent adverse events (TEAEs) and patient- and investigator-reported measures were also evaluated. Results Compared with IR-CD/LD, treatment with either AP-CD/LD dose resulted in more stable LD plasma concentrations in both fluctuating and non-fluctuating PD patients, and significantly decreased Cmax (57.1% and 66.8% decreases among fluctuating and non-fluctuating patients, respectively). Both AP doses significantly improved standard measures of motor symptoms: (daily OFF time, total ON time, and good ON time), as well as patient- and investigator-assessed measures, versus IR-CD/LD. The safety and tolerability profile of AP-CD/LD was consistent with the known properties of IR-CD/LD. Conclusions AP technology demonstrated effective controlled-release PK performance and reduced motor response fluctuations in advanced PD patients. A phase 3 randomized controlled trial is currently underway.

Background A high-risk subgroup of older patients with depression has slowed processing and gait speeds. This study examined whether carbidopa/levodopa (L-DOPA) monotherapy increased dopamine availability, increased processing/gait speed, and relieved depressive symptoms. Methods Adult outpatients with depression >59 years old underwent baseline [11C]raclopride positron emission tomography followed by open L-DOPA for 3 weeks (1 week each of 150 mg, 300 mg, and 450 mg). Generalized estimating equations tested the pre- and post-L-DOPA differences in processing and gait speed measures, depressive symptoms, and reported side effects. The decrease in binding potential between the pre- and posttreatment scans indexed enhanced synaptic dopamine availability induced by L-DOPA treatment. Results Thirty-six subjects participated (age, 75.3 ± 7.5 years; 44.4% male). Significant, dose-dependent increases in processing and gait speed were observed with L-DOPA (450-mg dose: processing speed factor score effect size = 0.41, p = .001; dual-task gait speed effect size = 0.43, p = .002). [11C]raclopride decrease in binding potential was significantly different from 0 in sensorimotor (t24 = −4.85, p Conclusions By enhancing availability of dopamine, L-DOPA improved processing and gait speed in older adults with depression and significantly decreased [11C]raclopride binding in selected striatal subregions.

Herein, we fabricated fluorescent gold nanoclusters (Au NCs) by using trypsin as a ligand. The fabricated trypsin-Au NCs emit bright red color fluorescence upon the exposure of 365 nm UV light. The trypsin-Au NCs are stable and well dispersed in water, which exhibited strong red emission peak at 665 nm upon excitation wavelength of 520 nm. The red fluorescence of trypsin-Au NCs was greatly quenched by the addition of multiple analytes such as drugs (carbidopa and dopamine) and three divalent metal ions (Cu2+, Co2+ and Hg2+ ion). As a result, a novel fluorescence “turn-off” probe was developed for the detection of the above analytes with good selectivity and sensitivity. This method exhibits the detection limits for carbidopa, dopamine, Cu2+, Co2+ and Hg2+ ions are 6.5, 0.14, 5.2, 0.0078, and 0.005 nM, respectively. The trypsin-Au NCs were successfully applied to detect drugs (carbidopa, and dopamine) in pharmaceutical samples and metal ions (Cu2+, Co2+ and Hg2+ ion) in biofluids and water samples, exhibiting good precision and accuracy, which offers a facile analytical strategy for assaying of the above analytes in pharmaceutical and biological samples.

Background: The release of neurotransmitters could promote neuroprotection and facilitate neuroplasticity. We evaluate in a randomized study the benefit of levodopa and serotonin in stroke patients. Methods: SELEIS was a unicenter, double-blind, randomized, placebo-controlled trial. Patients with a first ischemic stroke were randomly assigned between 0-5 days after onset in four arms: 1) placebo, 2) citalopram 20 mg / day, 3) levodopa/carbidopa 100/25 mg / day and 4) citalopram 20 mg / day plus levodopa/carbidopa 100/25 mg/ day for 6 months. The primary outcome measure was the percentage on independent functional status (mRS 0-2) at 12 months. Secondary end points were the change in size of acute infarction by MRI (T2) and cognitive improvement assessment at 12 months. This trial was registered in the registry ClinicalTrials.gov, number NCT02386475. Findings: Of 225 patients evaluated, 44 were finally randomly assigned to placebo (n=11), citalopram (n=9), levodopa (n=11) and citalopram plus levodopa (n=13). We did not detect any serious adverse event and six patients abandoned treatment for minor digestive disorders, insomnia or drowsiness. At 12 months the only group with a significant reduction greater than 50% of initial lesion volume, was the citalopram plus levodopa (placebo 33% vs 71% citalopram vs 73% levodopa vs 87.5% citalopram and levodopa, p=0.02). We did not detect significant differences between the groups in the functional or cognitive state at 12 months. Interpretation: The treatment with citalopram plus levodopa significantly reduced the lesion volume at 12 months, supporting the hypothesis of neurotrophic mechanism, although this reduction was not correlated with clinical improvement. Trial Registration: NCT02386475. Funding Statement: The study was sponsored by the Hospital General de Granollers. Declaration of Interests: The authors report no conflicts of interest and non-financial disclosures Ethics Approval Statement: The protocol was approved by the Ethic Committee.

Levodopa (L-DOPA) is a first line drug for treating Parkinson’s disease and prescribed in combination with carbidopa orally and is associated with nausea and poor bioavailability. In the present work levodopa microemulsions were developed, administered intra nasally and pharmacokinetics Plasma, brain, pharmacodynamics were evaluated in comparison to oral route in rat model. Levodopa microemulsions (ME) were prepared by water titration method. Optimized formulation (ME16) was composed of oil (Oleic acid), Smix (Tween 80: PEG400: Ethanol; 1:1:0.25) water and drug in the ratio 5:60:35:2.5. The globule size, zeta potential and steady state flux of the optimized formulation were 96 nm, -33.6 mV and 57.53μg/cm2/h respectively. Chitosan was added at 0.5% concentration to optimized microemulsion formulation as permeation enhancer. The flux of the MME was significantly higher (70.29μg/cm2/h) than microemulsion. The zeta potential of MME was 13.2 mV which is due to presence of cationic polymer. The formulations ME16 and MME showed significantly higher flux which is 3.09 and 3.78 times higher than drug solution. The pharmacokinetics plasma, brain and pharmacodynamic studies were carried out on male wister rats. Bioavailability of ME brain was 1.6 times and MME brain was 3.06 folds to oral drug solution The drug targeting efficiency (DTE) and direct nose to brain transport (DTP%) were 2.77 and 66.7% for MME and 1.72 ,45.57% for ME which were significantly high compared to oral drug solution (0.9). Antiparkinson’s activity of optimized formulation, drug solution via nasal route in comparison to oral solution was studied in rotenone induced male wistar rats. Optimized ME16 and MME formulation treated group showed significant increase (P

The dopamine overdose hypothesis has provided an important theoretical framework for understanding cognition in Parkinson's disease. It posits that effects of dopaminergic therapy on cognition in Parkinson's disease depend on baseline dopamine levels in brain regions that support different functions. Although functions performed by more severely dopamine-depleted brain regions improve with medication, those associated with less dopamine deficient areas are actually worsened. It is presumed that medication-related worsening of cognition owes to dopamine overdose. We investigated whether age-related changes in baseline dopamine levels would modulate effects of dopaminergic therapy on reward learning in healthy volunteers. In a double-blind, crossover design, healthy younger and older adults completed a probabilistic reversal learning task after treatment with 100/25 mg of levodopa/carbidopa versus placebo. Older adults learned more poorly than younger adults at baseline, being more likely to shift responses after misleading punishment. Levodopa worsened stimulus-reward learning relative to placebo to the same extent in both groups, irrespective of differences in baseline performance and expected dopamine levels. When order effects were eliminated, levodopa induced response shifts after reward more often than placebo. Our results reveal independent deleterious effects of age group and exogenous dopamine on reward learning, suggesting a more complex scenario than predicted by the dopamine overdose hypothesis.

l -dopa is still the cornerstone symptomatic medication for Parkinson disease (PD), although it cannot stop the neurodegenerative process progression or even aggravate it. Filgrastim (G-CSF) is a hematopoietic growth factor, exhibited neurotrophic, antioxidant, anti-apoptotic, immunomodulating and neuroprotective potentialities. The present study assessed the possible modulating potentialities of filgrastim on l -dopa treatment’s drawbacks in a mouse model of PD. Male BALB/c mice received 30 mg/kg/day rotenone suspended in 0.25 ml 0.5% CMC in PBS for 28 days orally from day 1st until the day 28th of the experiment for induction of PD. Since day 29th till day 43rd, mice treated with either 10 mg/kg/day l -dopa and 2.5 mg/kg/day carbidopa suspended in 0.25 ml 0.5% CMC in PBS orally, 50 μg/kg/day filgrastim in 0.1 ml 5% dextrose SC or a combination of both. Filgrastim, in the present study, able to alleviate the l -dopa therapy’s drawbacks in PD that revealed by the restoration of the exhausted nigrostriatal GSH level, and the reduction of the elevated nigrostriatal MDA, NO and TNF-α levels that deteriorated by l -dopa therapy. Moreover, the co-therapy of filgrastim with l -dopa, considerably potentiated the deteriorated mice’s working memory, and abrogated the nigrostriatal histopathological changes and caspase-3 immunohistochemical expression, failed to improve by l -dopa therapy. Furthermore, the filgrastim co-therapy with l -dopa demonstrated a remarkable improvement in the nigrostriatal dopamine level, and repression of rotenone-induced descent latency prolongation, as well as, stride length reduction than each alone. Therefore, filgrastim is promising, as a disease-modifying therapy, in amelioration of l -dopa therapy’s drawbacks in PD.

Substantial evidences suggest that reactive oxygen species participate in the normal aging process and in cancer and neurodegenerative age-related diseases. Parkinson's disease (PD), one of the most common oxidative stress-associated pathology in aging people, is treated with a standard pharmacological protocol consisting in a combined therapy L-dopa plus an inhibitor of dopa-decarboxylase, such as carbidopa. The therapy is well validated for the ability to restoring dopaminergic neurotransmission in PD patients, while L-dopa and carbidopa ability in modulating oxidative stress is currently under discussion. Our aim was to evaluate the impact of L-dopa and carbidopa on several biomarkers of exogenously-induced oxidative stress to validate the overall antioxidant effectiveness of the therapy. For this purpose we used peripheral blood lymphocytes from healthy donors treated in vitro with L-dopa and carbidopa and then challenged by different concentrations of H2O2. Glutathione (GSH, GSSG, GSH/GSSG), malondialdehyde (TBARs), protein carbonyls as well as DNA damage (8-oxo-7,8-dihydro-2′-deoxyguanosine (8-oxodG) and micronuclei (MN)), modulation was evaluated. Our results show that L-dopa, but not carbidopa, decreases the markers of lipid and protein oxidation and increases the total content of glutathione. Both L-dopa and carbidopa (alone or in combination) are able to counteract the formation of 8-oxodG and to reduce H2O2-induced micronuclei. © 2017 Elsevier Ltd

Patients with hyperphenylalaninemia (HPA) are detected through newborn screening for phenylketonuria (PKU). HPA is known to be caused by deficiencies of the enzyme phenylalanine hydroxylase (PAH) or its cofactor tetrahydrobiopterin (BH4). Current guidelines for the differential diagnosis of HPA would, however, miss a recently described DNAJC12 deficiency. The co-chaperone DNAJC12 is, together with the 70kDa heat shock protein (HSP70), responsible for the proper folding of PAH. All DNAJC12-deficient patients investigated to date responded to a challenge with BH4 by lowering their blood phenylalanine levels. In addition, the patients presented with low levels of biogenic amine in CSF and responded to supplementation with BH4, L-dopa/carbidopa and 5-hydroxytryptophan. The phenotypic spectrum ranged from mild autistic features or hyperactivity to severe intellectual disability, dystonia and parkinsonism. Late diagnosis result in permanent neurological disability, while early diagnosed and treated patients develop normally. Molecular diagnostics for DNAJC12 variants are thus mandatory in all patients in which deficiencies of PAH and BH4 are genetically excluded.

Sulfasalazine is an anti-inflammatory agent commonly used in the treatment of autoimmune conditions such as inflammatory bowel disease and rheumatoid arthritis. Sulfasalazine is converted by gut bacteria into sulfapyridine and the clinically active metabolite 5-aminosalicylic acid (5-ASA), and its efficacy is proportional to the 5-ASA concentration within the intestinal lumen. Renal complications are commonly reported for the chemically similar 5-ASA derivative mesalamine, but are not well-known side effects of sulfasalazine therapy. We report a 72-year-old patient with Crohn's disease managed with sulfasalazine for more than 10 years who presented with severe acute kidney injury (serum creatinine, 9.7mg/dL). Renal ultrasound revealed calculi and he subsequently spontaneously voided innumerable stones, which were composed of sulfasalazine metabolites. His renal calculi cleared and serum creatinine concentration improved to 3.1mg/dL after discontinuing sulfasalazine therapy and intravenous fluid hydration. His kidney function eventually returned to baseline. This case demonstrates that renal complications, in particular nephrolithiasis, may be an under-reported but potentially serious phenomenon in patients with inflammatory bowel disease treated with sulfasalazine and that their hydration status may play an important role in this process.

Background Effective treatment for advanced Parkinson disease (PD) uncontrolled with oral medication includes device-aided therapies such as deep brain stimulation (DBS) and continuous levodopa-carbidopa infusion to the duodenum via a portable pump. Objective Our objective was to quantify patient preferences for attributes of these device-aided treatments. Methods We administered a Web-enabled survey to 401 patients in the United States. A discrete-choice experiment (DCE) was used to evaluate patients' willingness to accept tradeoffs among efficacy, tolerability, and convenience of alternative treatments. DCE data were analyzed using random-parameters logit. Best-worst scaling (BWS) was used to elicit the relative importance of device-specific attributes. Conditional logit was used to analyze the BWS data. We tested for differences in preferences among subgroups of patients. Results Improving ability to think clearly was twice as important as a 6-hour-per-day improvement in control of movement symptoms. After controlling for efficacy, treatment delivered via portable infusion pump was preferred over DBS, and both devices were preferred to oral therapy with poor symptom control. Patients were most concerned about device attributes relating to risk of stroke, difficulty thinking, and neurosurgery. Avoiding surgery to insert a wire in the brain was more important than avoiding surgery to insert a tube into the small intestine. Some differences in preferences among subgroups were statistically, but not qualitatively, significant. Conclusions This study clarifies the patient perspective in therapeutic choices for advanced PD. These findings may help improve communication between patients and providers and also provide evidence on patient preferences to inform regulatory and access decisions.

The levodopa/carbidopa intestinal gel (LCIG) is an efficacious treatment for Parkinson disease. The initiation and management of the LCIG requires a streamlined approach that takes into account patient heterogeneity. In this article we outline an over arching approach to this while highlighting steps that could be potentially modified in each individual, with the ultimate goal of achieving ideal clinical outcomes.

Background Chronic cocaine users show impairments in cognitive processes associated with dopamine (DA) circuitry. Medications aimed at bolstering cognitive functions via DA modulation might enhance treatment outcome. Methods The trial used a double-blind, double-dummy, parallel-group design with four treatment arms comparing placebo (PLC) to levodopa/carbidopa 800 mg/200 mg alone (LR0), levodopa plus extended release (XR) ropinirole 2 mg (LR2) or XR ropinirole 4 mg (LR4). Adults (n = 110) with cocaine use disorder attended thrice weekly clinic visits for 10 weeks. Potential cognitive mediators assessed at week 5 consisted of measures of decision-making (Iowa Gambling Task, Risky Decision-Making Task), attention/impulsivity (Immediate Memory Task), motivation (Progressive Ratio task), and cognitive control (Cocaine Stoop task). The primary outcome measure was the treatment effectiveness score (TES) calculated as the number of cocaine-negative urines collected from weeks 6–10. Results Bayesian mediation examined indirect and total effects of the relationships between each active treatment (compared to PLC) and TES. Total (direct) effects were supported for LR0 and LR2, but not for LR4. Indirect effects were tested for each mediator. Notably, 22.3 % and 35.4 % of the total effects of LR0 and LR2 on TES were mediated by changes in attention/impulsivity. Conclusions The hypothesized mediation effect was strongest for levodopa plus 2 mg ropinirole, indicating that this DA medication combination predicted change (improvement) in attention/impulsivity, which in turn predicted change (reduction) in cocaine use. This finding provides modest support for cognitive enhancement as a target for medications to treat cocaine use disorder.

Levodopa, the metabolic precursor of dopamine, is usually administrated in combination with carbidopa to control dopamine levels in an appropriate manner and reduce side effects in the treatment of Parkinson's disease. In this study, a selective and sensitive high performance liquid chromatography coupled with on-line gold nanoparticles-catalyzed luminol chemiluminescence method for simultaneous determination of levodopa and carbidopa was developed. This method was based on the strongly enhanced chemiluminescence signal of on-line gold nanoparticles-catalyzed luminol-H2O2 system by levodopa and carbidopa. The possible enhancement mechanism was attributed to that levodopa and carbidopa could promote the on-line formation of a large number of gold nanoparticles, which catalyzed the luminol-H2O2 chemiluminescence reaction. The good separation of levodopa and carbidopa was achieved with isocratic elution using a mixture of methanol and 0.2% aqueous phosphoric acid (5:95, V/V) within 10.5 min. Under the optimal conditions, the linear ranges of levodopa and carbidopa were 2.24–448 ng mL−1 and 4.32–1080 ng mL− with the detection limits of 0.89 and 1.08 ng mL− (S/N = 3), corresponding to 17.92 and 21.60 pg for 20 μL sample injection, respectively. The validated method was successfully applied to simultaneous quantification of levodopa and carbidopa in controlled-release tablets (Sinemet®) and human plasma. The average recoveries of levodopa and carbidopa in the tablets were 100.5% and 103.1% with the precisions (RSDs) of 2.4% and 4.0%. The recoveries of levodopa and carbidopa in human plasma ranged from 97.0% to 103.5% with RSDs of no more than 3.3%.

A simple and selective bioanalytical method was developed for simultaneous determination of levodopa and carbidopa in rat plasma by LC-MS/MS. Levodopa and carbidopa are small polar molecules, posing challenges in the development of selective and efficient chromatography conditions. Perfluoropentanoic acid (PFPA), a volatile ion-pairing agent, was utilized to enhance chromatographic characteristics of both compounds in the reversed-phase mechanism. The ion-pairing chromatography played an essential role in mitigating matrix effects and achieving adequate separation between interfering background peaks and those of the analytes of interest, especially for levodopa. A 96-well based, automated liquid-liquid extraction, via the use Hamilton NIMBUS liquid handlers, was developed. Butyl alcohol, when mixed with ethyl acetate, greatly increased the recovery of both levodopa and carbidopa. The addition of PFPA further enhanced recovery for both analytes. Sodium metabisulfite, an antioxidant, was used to stabilize levodopa and carbidopa in rat plasma. The method was validated in the ranges of 50-10,000ng/mL and 25-5000ng/mL for levodopa and carbidopa, respectively, using levodopa-d3 and carbidopa-d3 as internal standards. The validated method was successfully applied to analyze rat plasma samples from in-life studies.

Background IPX066 (Rytary®; carbidopa and levodopa [CD-LD] extended-release capsules) was designed to achieve therapeutic LD plasma concentrations within 1 h of dosing and maintain LD concentrations for a prolonged duration in early or advanced Parkinson's disease (PD). Methods In this open-label study, patients underwent 6 weeks of conversion to IPX066 from their prior controlled-release (CR) ± immediate-release (IR) CD-LD therapy and 6 months of maintenance (with an additional 6 months of IPX066 at some sites). Clinical utility was assessed at both the end of conversion and maintenance. Results Among 43 patients initiated on IPX066, 33 completed conversion. The mean LD conversion ratio was 1.8 among 30 patients previously on CR plus IR (and 1.5 among 3 previously taking CR alone). The mean IPX066 dosing frequency was 3.5 times/day compared with 2.6 times/day for CR plus 4.6 times/day for IR previously (and 4.7 times/day for CR alone). By patient and clinician global improvement ratings after 6-month maintenance, ≥ 43.8% of patients were much or very much improved from their previous treatment, and ≥ 68.8% were at least minimally improved. Adverse events were consistent with those reported in prior IPX066 studies. Conclusions These results suggest that advanced PD patients using CR CD-LD ± IR can be safely converted to IPX066, with high likelihood of achieving a stable regimen, less frequent LD dosing, and improved overall clinical benefit. Trial registration: Clinicaltrials.gov NCT01411137 .

Purpose To investigate whether the different role of ocular dopamine was involved in the myopic development between spontaneous myopia (SM) and form deprivation myopia (FDM) in albino guinea pigs. Methods 55 myopic animals were randomly divided into SM, Levodapa (L-DOPA), L-DOPA + carbidopa and vehicle. 70 non-myopic animals were randomly divided into normal control, FDM, L-DOPA + FDM, L-DOPA + carbidopa + FDM and vehicle. Once per day, for 14 days, L-DOPA (10 mg/kg) was injected intraperitoneally, and carbidopa (1 μg) was injected at the same time into the peribulbar space of the right eye. Refractive parameters and dopamine content in neural retina and RPE/choroid complex were measured. Results In SM animals, high myopia was formed at 5 week of ages. L-DOPA treatment could reduce its myopic degree, and inhibit the increase of axial length and vitreous chamber depth with the increase of retinal dopamine in both eyes. Administration of carbidopa could prevent the increase of retinal dopamine induced by L-DOPA, but no influenced on its refractive state in the injected eyes. In non-SM animals, intraperitoneal L-DOPA could inhibit FDM, accompanied by the increase of retinal dopamine. Carbidopa treatment diminished the inhibition of FDM and prevented the increase in retinal dopamine by L-Dopa. Retinal dopamine was highly correlated with ocular refraction in FDM, but not in SM. There was no significant difference in dopamine content of RPE/choroid complex among all groups. Conclusions The role of retinal dopamine was different between SM and FDM in albino guinea pigs. Although systemic L-DOPA could inhibit the development of SM and FDM, retinal dopamine was only involved in the L-DOPA inhibition on FDM, but not on SM.

Background and objective Levodopa/carbidopa intestinal gel infusion is a treatment option for patients of advanced stage of Parkinson's disease. This treatment requires the time-consuming and error-prone conversion of orally taken antiparkinson drugs into an equivalent replacing dose of levodopa/carbidopa, which is delivered via pump. In order to facilitate and speed up this conversion process, we developed a specific user-friendly application that would be available online or as a standalone mobile application. Such an application has now been written and designed in collaboration with a computer scientist and physician, who is also intended to be the final user. Methods The levodopa equivalent dose calculations are based on previous studies and data reported in the literature. Two related on-line conversion applications were analyzed and evaluated. The primary objectives of the application were determined, and basic functionalities were outlined. The application was implemented using modern development tools and frameworks. Results The application has proven to be effective and easy to use in our clinical setting. It can serve as a control for manual calculations made by medical staff. It can also be applied as a useful tool in levodopa/carbidopa intestinal gel infusion courses for the advanced treatment of Parkinson's disease. Conclusion The presented application could replace the tedious and error-prone levodopa equivalent dose conversion of antiparkinson drugs efficiently. In comparison to related on-line conversion applications, this specific application provides more functionality, reduces the risk of user errors, and can be run on a variety of devices. The conversion value provided by the application is only an estimate. The effect of the drugs is specific for each individual patient, which could not be considered in the calculations. Therefore, the responsibility of using the results of the application rests with the clinical judgment of the user. Nevertheless, the application can give us a good starting point for the initial pump setting, which would be adjusted further during the titration period, according to the patient's response.

Neuroinflammation and angiogenesis have been involved in the pathogenesis of Parkinson's disease (PD). This study investigated the effect of ibuprofen or piroxicam on the motor response to l -dopa and development of dyskinesia in Parkinsonian rats focusing on the anti-angiogenic role of the two non-steroidal anti-inflammatory drugs (NSAIDs). Rats were divided into nine groups as follows: Group I: the vehicle group, Group II: rotenone group, rats were injected with nine doses of rotenone (1 mg/kg/48 h), group III&IV: rats received rotenone + ibuprofen (10 or 30 mg/kg), Group V-VI: rats received rotenone + piroxicam (1 or 3 mg/kg), Group VII: rats received rotenone + l -dopa/carbidopa (100/10 mg/kg), Group VIII-IX: rats received rotenone + l -dopa/carbidopa + ibuprofen (30 mg/kg) or piroxicam (3 mg/kg). In general, drugs were administered daily for ten weeks. Rotenone-treated rats showed motor dysfunction, lower striatal dopamine, lower staining for nigral tyrosine hydroxylase but higher level of striatal cyclooxygenase-2 (COX-2) and vascular endothelial growth factor (VEGF) compared to vehicle-treated rats (P l -dopa showed wearing-off over the course of the experiment in addition to development of abnormal involuntary movements and upregulated striatal VEGF level. Treatment with ibuprofen or piroxicam in combination with l -dopa preserved the effect of l -dopa at the end of week 10, delayed the development of dyskinesia and decreased striatal COX-2 and VEGF levels. In conclusion, the current study suggests that ibuprofen and piroxicam are promising candidates for neuroprotection in PD and may have utility in conjunction with l -dopa in order to ensure the longevity of its action and to delay the development of dyskinesia.

While Parkinson's disease (PD) is traditionally viewed as a motor disorder, there is mounting evidence that somatosensory function becomes affected as well. However, conflicting reports exist regarding whether plantar sensitivity is reduced in early-onset PD patients. Plantar sensitivity was assessed using monofilaments and a gold-standard, two-interval two-alternative forced choice vibrotactile detection task at both 30 and 250Hz. Lower-limb cutaneous reflexes were assessed by delivering continuous, sinusoidal vibration at 30 and 250Hz while recording muscle activity in Tibialis Anterior. We found no evidence of elevated plantar thresholds or dysfunctional lower-limb cutaneous reflexes in PD patients ON medication. We also found no acute effect of ceasing L-dopa intake on either plantar sensitivity or cutaneous reflexes. Our finding of intact cutaneous function in PD supports the further exploration of therapeutics that enhance plantar sensitivity to minimize postural instability, a source of considerable morbidity in this clinical population.

Background Classic L-dopa–responsive dystonia is characterized by the triad of dystonia, diurnal fluctuation of signs, and dramatic response of signs to low-dose L-dopa therapy. Dopa-responsive dystonia succinctly summarizes the relevant clinical features. However, literal application of this label or consideration of dopa-responsive dystonia as a diagnostic end without molecular and/or biochemical definition may contribute to misdiagnosis and incomplete treatment in dopa-responsive conditions that impair synthesis of monoamine neurotransmitters besides dopamine. Patient Description We describe and provide video for twin patients with a rare form of dopa-responsive dystonia due to sepiapterin reductase deficiency. As is typical in dopa-responsive dystonia, these patients displayed dramatic improvement with L-dopa/carbidopa therapy. However, treatment was suboptimal until 5-hydroxytryptophan was added to address their serotonergic deficit. Discussion Our report highlights the limitations of the dopa-responsive dystonia label and increases awareness of sepiapterin reductase deficiency and other conditions that may present as dopa-responsive dystonia. We provide a diagnostic and therapeutic approach to guide the clinician in evaluating and treating individuals with dopa-responsive dystonia.

Introduction: Tremor is thought to be a rare feature of progressive supranuclear palsy (PSP). Methods: We retrospectively reviewed the database of the CurePSP brain bank at Mayo Clinic Florida to retrieve all available clinical information for PSP patients. All patients underwent a standard neuropathological assessment and an immunohistochemical evaluation for tau and alpha-synuclein. DNA was genotyped for the MAPT H1/H2 haplotype. Results: Of the 375 PSP patients identified, 344 had a documented presence or absence of tremor, which included 146 (42%) with tremor, including 29 (20%) with postural/action tremors, 16 (11%) with resting tremor, 7 (5%) with intention tremor, 20 (14%) with a combination of different types of tremor, and 74 (51%) patients who had tremor at some point during their illness, but details were unavailable. The tremor severity of 96% of the patients (54/55) who had this data was minimal to mild. The probability of observing a tremor during a neurological examination during the patient's illness was estimated to be similar to 22%. PSP patients with postural/action tremors and PSP patients with resting tremor responded to carbidopa-levodopa therapy more frequently than PSP patients without tremor, although the therapy response was always transient. There were no significant differences in pathological findings between the tremor groups. Conclusions: Tremor is an inconspicuous feature of PSP; however, 42% (146/344) of the PSP patients in our study presented some form of tremor. Because there is no curative therapy for PSP, carbidopa/levodopa therapy should be tried for patients with postural, action, and resting tremor. (C) 2016 Elsevier Ltd. All rights reserved.

Parkinson's disease (PD) is a chronic and progressive neurodegenerative disorder. Its estimated prevalence is 1 million individuals in the United States, with approximately 60,000 people newly diagnosed in the US every year. The incidence and diagnosis of PD will increase in the next decades as our population ages. Nurse practitioners will need to be familiar with the presentation and progression and pharmacologic treatment of PD. This disease has a broad range of motor and nonmotor manifestations. The present article reviews medication treatment for both motor and nonmotor symptoms of PD.

We report the efficacy and adverse effect profile of intraduodenal levodopa-carbidopa intestinal gel (LCIG) infusion from patients treated in a single Australian movement disorder centre. We conducted an open-label, 12 month prospective study of treatment with LCIG in patients with advanced Parkinson's disease in a single tertiary referral hospital unit specialising in movement disorders. Patients with levodopa-responsive, advanced Parkinson's disease with motor fluctuations despite optimal pharmacological treatment were enrolled and underwent a 16 hour daily infusion of LCIG for 12 months. Fifteen participants completed the trial. The mean (± standard deviation) improvement in Unified Parkinson's Disease Rating Scale part III was 37 ± 11%, mean daily "off" period reduced from 6.3 ± 2 to 1.9 ± 2 hours, total daily "on" time increased from 10.2 ± 3 to 13.7 ± 2 hours, "on" period without dyskinesia increased from 4.5 ± 3 to 7.5 ± 5 hours, and 39-item Parkinson's Disease Questionnaire Summary Index score improved by 32.5 ± 35%. The most common adverse event was reversible peripheral neuropathy secondary to vitamin B12 ± B6 deficiency (40%), local tube problems (40%), and impulse control disorder (ICD) (27%). No patient had stoma bleeding or peritonitis. All patients with ICD had a past psychiatric diagnosis of depression with or without anxiety and a higher daily levodopa intake at 6 and 12 months of LCIG infusion. Intraduodenal LCIG improves motor performance, quality of life and daily "on" period. Prior to and during duodenal LCIG infusion, clinicians should monitor for peripheral neuropathy and vitamin B12 and B6 deficiency, as supplementation can reverse peripheral neuropathy. This trial is registered at Clinicaltrials.gov as CT00335153.

This review discusses the clinical value of 18F-dihydroxyphenylalanine positron emission tomography-computed tomography (18F-FDOPA PET/CT) across the spectrum of neuroendocrine tumors (NETs). The rationale for 18F-FDOPA imaging is generally based on the ability of NETs to take up and decarboxylate amine precursors. The kinetics of tumor uptake and retention varies according to tumor type. For some tumor types, the imaging protocol might include early-time acquisitions in order not to miss cases with rapid washout, or carbidopa premedication to overcome physiological pancreatic uptake. The roles of 18F-FDOPA PET/CT imaging will be examined in diverse settings of patients with MTC, digestive NET, congenital hyperinsulinism and pheochromocytomas/paragangliomas. In each clinical setting, the diagnostic accuracy of 18F-FDOPA PET/CT is compared to that offered by conventional imaging methods or other PET tracers, such as 68Ga-labeled somatostatin analogs or 18F-FDG.

Dopamine depletion in the putamen is associated with altered motor network functional connectivity in people with Parkinson's disease (PD), but the functional significance of these changes remains unclear, attributed to either pathological or compensatory mechanisms in different studies. Here, we examined the effects of PD on dorsal caudal putamen functional connectivity, off and on dopamine replacement therapy (DRT), using resting state fMRI. Motor performance was assessed with the Purdue pegboard task. Twenty-one patients with mild–moderate Parkinson's disease were studied twice, once after an overnight DRT washout and once after the administration of a standard dose of levodopa (Sinemet), and compared to 20 demographically-matched healthy control participants. PD patients off DRT showed increased putamen functional connectivity with both the cerebellum (lobule V) and primary motor cortex (M1), relative to healthy controls. Greater putamen–cerebellar functional connectivity was significantly correlated with better motor performance, whereas greater putamen–M1 functional connectivity was predictive of poorer motor performance. The administration of levodopa improved motor performance in the PD group, as expected, and reduced putamen–cerebellar connectivity to levels comparable to the healthy control group. The strength of putamen–cerebellar functional connectivity continued to predict motor performance in the PD group while on levodopa. These findings argue that increased putamen–M1 functional connectivity reflects a pathological change, deleterious to motor performance. In contrast, increased putamen–cerebellar connectivity reflects a compensatory mechanism., Highlights • We examined the functional significance of altered motor networks in Parkinson's. • Patients showed greater putamen–cerebellar and –motor cortex connectivity. • Greater putamen–cerebellar connectivity correlated with better motor performance. • Greater putamen–motor cortex connectivity correlated with worse motor performance. • l-Dopa normalized putamen–cerebellar connectivity and improved motor performance.

Levodopa-associated motor fluctuations and dyskinesia in patients with Parkinson's disease (PD) are often difficult to control by the oral administration of levodopa. Continuous infusion of a levodopa/carbidopa intestinal gel (LCIG) may represent a feasible treatment option for this patient population. To start LCIG infusion, a temporary nasoduodenal/nasojejunal tube should be considered to show that the patient responds favorably, before a permanent percutaneous endoscopic gastrostomy with jejunal tube (PEG-J) is placed. The present review focuses on recently published key studies on the efficacy and safety of LCIG treatment in advanced PD. The results provide robust evidence of a marked reduction of OFF-fluctuations and dyskinesia, thereby also improving the quality of life of these severely disabled patients. LCIG treatment is therefore a promising alternative to continuous subcutaneous apomorphine infusion or deep brain stimulation in advanced PD patients with severe motor fluctuations.

Lithium has recently been suggested to have neuroprotective effects in several models of neurodegenerative disease including Parkinson’s disease (PD). Levodopa (L-Dopa) replacement therapy remains the most common and effective treatment for PD, although it induces the complication of L-Dopa induced dyskinesia after years of use. Here we examined the potential use of lithium in combination with L-Dopa/Carbidopa for both reducing MPTP-induced abnormal involuntary movements (AIMs) as well as protecting against cell death in MPTP-lesioned mice. Chronic lithium administration (0.127% LiCl in the feed) in the presence of daily L-Dopa/Carbidopa injection for a period of 2 months was sufficient to effectively reduce MPTP-induced AIMs in mice. Mechanistically, lithium was found to suppress MPTP-induced calpain activities in vivo coinciding with down-regulation of calpain-1 but not calpain-2 expression in both the striatum (ST) and the brain stem (BS). Calpain inhibition has previously been associated with increased levels of the rate-limiting enzyme in dopamine synthesis, tyrosine hydroxylase (TH), which is probably mediated by the up-regulation of the transcription factors MEF-2A and 2D. Lithium was found to induce up-regulation of TH expression in the ST and the BS, as well as in N27 rat dopaminergic cells. Further, histone acetyltransferase (HAT) expression was substantially up-regulated by lithium treatment in vitro. These results suggest the potential use of lithium in combination with L-Dopa/Carbidopa not only as a neuroprotectant, but also for reducing AIMs and possibly alleviating potential side-effects associated with the current treatment for PD.

In this work, we synthesized fluorescent chicken egg white mediated platinum nanoclusters (CEW-Pt NCs) via one-step synthetic approach using chicken egg white as template as well as stabilizing agent. The-as synthesized fluorescent CEW-Pt NCs gives blue fluorescence at 365 nm of UV lamp. The fluorescent CEW-Pt NCs exhibit the emission at 406 nm when excited at 330 nm. Taking CEW-Pt NCs as a model nanoprobe, the fluorescence “turn-off” mechanism is developed for assaying of carbidopa based on the linear quenching of emission peak intensity at 406 nm. The carbidopa acts as a quencher, resulting to exhibit a linear response in the range of 5.0–35 μM with the detection limit of 1.71 μM. The fluorescence quenching of CEW-Pt NCs exhibits selectivity toward carbidopa over other similar drugs and chemical (inorganic and biomolecules). This method is shown to be a miniaturized analytical platform for assaying of carbidopa in its pharmaceutical samples and biofluids, which could open up a new and straightforward platform for assaying of carbidopa in real samples.

Droxidopa is a prescribed medication for the treatment of orthostatic hypertension in patients with pure autonomic failure and multiple system atrophy, which causes symptoms of lightheadedness and Parkinson’s disease. In the current study, a simple electrochemical sensor designed for simultaneously determination of droxidopa and carbidopa via using 2-(4-ferrocenyl-[1,2,3]triazol-1-yl)-1-(naphthalen-2-yl) ethanone (2FTNE) modified NiFe2O4 nanoparticles paste electrode (2FTNENFOCPE). The 2FTNENFOCPE exhibited exceptional electrochemical catalytic behavior against droxidopa and carbidopa. Chronoamperometry, cyclic voltammetry and differential pulse voltammetry (DPV) were used to explore the analytical performance of 2FTNENFOCPE for co-detection of droxidopa and carbidopa. The 2FTNENFOCPE is able to separate oxidation peak potentials of droxidopa and carbidopa about 440 mV. The detection limits achieved via DPV, for droxidopa and carbidopa were 6.0 × 10−8 and 3.0 × 10−7 M. In the final, the 2FTNENFOCPE was utilized successfully to measure the droxidopa and carbidopa in the real solutions.

Introduction Continuous infusion of levodopa/carbidopa intestinal gel (LCIG) is an effective treatment for patients with advanced Parkinson Disease (PD) that cannot be further improved by oral therapy. Methods We conducted an observational, prospective, and multicenter study to collect, in a large sample of PD treated with LCIG, long-term information about the outcome and safety of the treatment. The assessments were performed before LCIG, 1, 3, 6 months after, and ever since, every 6 months. Results We studied 72 patients with a mean observation time of 22 months and a maximum of 48 months. During follow-up 28 patients discontinued the treatment, especially for lack of efficacy or adverse events related to the drug. We obtained a significant improvement of motor and non-motor fluctuations, mean off time and some non-motor symptoms. A significant increase in the percentage of time with dyskinesias was found in patients having less than 50% of the day with dyskinesias before LCIG. However, patients having already many dyskinesias before LCIG experienced a significant decrease of the troublesome dyskinesias, meaning that outcomes might be different depending on specific clinical characteristics. Adverse effects were in general minor but one case of intestinal perforation and one of abdominal cellulite were observed. Conclusions We confirmed that LCIG is a very effective treatment option for advanced PD; however considering the findings that dyskinesia can increase and the potential for serious side effects, we suggest the necessity for development of guidelines that better define the profile of responders.

Background Levodopa-carbidopa intestinal gel (LCIG) provides continuous infusion and reduces “off” time in advanced Parkinson's disease (PD) patients with motor fluctuations despite optimized pharmacotherapy. Methods Clinical experience with 2 LCIG dosing paradigms from phase 3 studies was examined. In an open-label, 54-week study, LCIG was initiated as daytime monotherapy via nasojejunal (NJ) tube then switched to percutaneous endoscopic gastrojejunostomy (PEG-J) tube; adjunctive therapy was permitted 28 days postPEG-J. In a 12-week, double-blind, placebo-controlled, double-dummy trial, patients continued stable doses of existing anti-PD medications, but LCIG replaced daytime oral levodopa-carbidopa and was initiated directly via PEG-J. Results In the open-label study, 92% of 354 patients received monotherapy at post–PEG-J week 4; mean titration duration was 7.6 days; dosing remained stable post-titration (mean total daily dose [TDD] was 1572 mg at last visit). In the double-blind trial, 84% received polypharmacy; mean titration took 7.1 days for the LCIG arm (TDD post-titration: 1181 mg; n = 37). At post–PEG-J week 4, mean “off” time with LCIG was reduced by 3.9 h (open-label/monotherapy study) and 3.7 h (double-blind/polypharmacy trial). NJ treatment (open-label study only) required an additional procedure with related adverse events (AEs) and withdrawals. The most common AEs during PEG-J weeks 1–4 in the open-label/monotherapy and double-blind/polypharmacy trials, respectively, were complication of device insertion (35%, 57%) and abdominal pain (26%, 51%). Discontinuations due to nonprocedure/nondevice AEs were low (2.2%, 2.7%). Conclusion These results support the option of initiating LCIG with or without NJ and as either monotherapy or polypharmacy.