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Background: Antiparkinson drugs (APDs) are the mainstay of managing Parkinson's disease (PD). However, there is paucity of evidence documenting patterns of APD use and examining factors associated with adherence to APDs., Objectives: Our goal was to provide updated, comprehensive population-based data on APD use and adherence and to examine characteristics associated with adherence behaviors., Methods: We analyzed data from 7583 beneficiaries with PD who had ≥ 2 APD prescription fills and were continuously enrolled in Medicare Parts A, B, and D for up to 19 months (from June 1, 2006, through December 31, 2007) or until death in 2007. We assessed 5 patterns of APD use: (1) concurrent use of ≥ 2 APD classes for ≥ 30 days; (2) switching of APDs from 1 to another; (3) augmentation of the existing regimen with a new APD; (4) duration of therapy, defined as days of APD treatment; and (5) adherence measured by using the medication possession ratio (MPR). We corrected for sample selection bias inherent in patients' self-selection into either a Part D plan or a Medicare Advantage Prescription Plan by using Heckman's 2-stage procedures., Results: APD users were pre-dominantly aged ≥ 65 years (93.6%), female (59.9%), and white (89.3%). Almost one half (43.2%) of APD users concurrently used ≥ 2 APD classes. One in 4 APD users experienced changes in their APD regimen, with 16.4% switching medications and 21.1% augmenting their current regimen. Three quarters of APD users had therapy lasting ≥ 436 days (75.3%) and an MPR ≥ 0.8 (72.7%). Multivariate analyses revealed that patients aged ≥ 65 years, of non-white race, non-low-income subsidy recipients, late Part D enrollees, cognitively impaired, highly comorbid, and who experienced multiple changes in APD therapy were less likely to adhere to APD therapy. We were able to generalize our findings to all Part D enrollees by correcting for sample selection bias using the Heckman approach. These population-level, generalizable observations provide better understanding of APD use and adherence and assist in the design of interventions for poor adherence. Limitations include cross-sectional study design and constraints in administrative data that preclude measurement of other potential factors related to adherence., Conclusions: A substantial proportion of these Medicare beneficiaries with PD used multiple APDs concurrently, experienced switching and/or augmentation of APDs, and had poor adherence to APDs. Patient characteristics and clinical and drug-related factors were important predictors of APD adherence., (© 2013 Elsevier HS Journals, Inc. All rights reserved.)

The diagnosis and treatment of Parkinson's disease (PD) typically occur when the disease has already progressed to a relatively advanced stage in which motor symptoms are clearly evident and substantial neurophysiological damage has already taken place. Nonmotor symptoms, which account for a large proportion of PD symptoms, usually emerge much earlier and offer both an early indication for treatment and a therapeutic target. A growing body of data from the medical literature points to several critical advantages that may be associated with early therapeutic intervention in PD. The most evident benefit of early intervention is a reduction in symptoms, particularly dyskinesia, and the delay of levodopa initiation. Clinical trials suggest but have yet to conclusively demonstrate that early treatment can slow disease progression. Both the diminishment of symptoms and the potential for slowing disease progression have large implications for improving patient quality of life. The enormous direct costs associated with PD would also likely be reduced over the long term with earlier treatment. The great majority of costs attributable to PD occur when the disease is at its most advanced stage and when symptoms are most severe. An early-treatment strategy that diminishes symptoms and that has the potential to slow disease progression could have a meaningful impact on PD expenditures. Adherence, too, must be taken into consideration, particularly since PD patients are generally poorly adherent to prescribed therapies, especially therapies with complex dosing schedules. Taking advantage of more convenient and adherencefriendly drug formulations may further help to improve outcomes and lower costs in PD.

Objectives: This study examined the treatment patterns, direct healthcare costs and predictors of treatment costs associated with levodopa-induced dyskinesia (LID) in Parkinson's disease (PD)., Methods: This retrospective cohort study followed PD patients for 1-year pre- and post-onset of LID, using a large US health insurance claims database from January 1, 2004 to December 31, 2008. Patients with LID were matched to patients without LID based on propensity scores to control for potential selection bias. Descriptive statistics and bootstrap techniques were employed to assess patient demographic and clinical characteristics and costs incurred. Factors influencing treatment costs were analyzed using a generalized linear model with log-link function and gamma distribution. Costs were adjusted to 2009 prices., Results: After patients developed LID, their total treatment costs were increased from $18,645 during the 12 months preceding LID onset to $26,439 for the 12-month period subsequent to LID onset (incremental costs of $7795: P<0.001). PD-related costs increased from $3917 to $8110 (incremental costs of $4194: p<0.001) LID events, medical resource utilization, higher levodopa dosage, and use of alternative PD medications were associated with increases in total treatment costs. Few changes in medication treatment patterns were noted following the initial LID, with only slight increases in levodopa dosage and few additions of alternative agents., Conclusions: In the United States, PD patients with LID impose a significant economic burden when compared to patients without LID. Currently available, treatment strategies for dyskinesia should be used more frequently in PD management, and new treatment strategies should be considered as they may lower healthcare costs., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Treatment of seniors with Parkinson disease is within the domain of primary care physicians and internists. A good working knowledge of carbidopa/levodopa principles should allow excellent care of most patients, at least during the early years of the disease. Even later, when levodopa responses become more complicated (eg, dyskinesias, motor fluctuations, insomnia, anxiety), levodopa adjustments may be all that is necessary. A dozen tips for optimizing treatment of Parkinson disease are discussed herein.

There is an ongoing debate about generic drug use for a multitude of conditions including epilepsy, psychosis, hypertension, post-organ transplantation, and several infectious diseases. Most of the concerns involve drugs with narrow therapeutic indices. There is a heightened attention to health care costs and macroeconomic policy as well as microeconomic business decisions that may impact the use of generic drugs. The issues surrounding generic substitution for chronic degenerative conditions such as in Parkinson's disease (PD) continue to be controversial subjects for physicians, pharmacists, patients, Medicare/governmental insurance programs, and for private insurance companies. The United States Food and Drug Administration (FDA) requires that generic drugs meet a standard for bioequivalence prior to market approval, but this may not translate to therapeutic efficacy or to overall patient tolerance. In this review we will address issues related to the use of generics versus branded drugs in PD, and the potential impact substitution of generics may have on patients and on clinicians. Having proper documentation may help in deciding the appropriate usage of these drugs in PD. Medicare, governmental run health care systems, and third party insurance companies should in a complex disease such as PD, allow physicians and patients the chance to properly document the superiority of brand versus generic approaches. Currently, in the U.S, and in many countries around the world, there is no obligation for payers to respect these types of patient specific bedside trials, and there has been no standardization of the process., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: As Parkinson's disease (PD) progresses, patients and their families experience substantial health and economic burdens. Because motor fluctuations (also called 'off-time') are linked to poor quality of life and higher healthcare costs, minimizing off-time is an effective strategy for reducing costs associated with PD., Objective: To assess the cost utility of rasagiline or entacapone as adjunctive therapies to levodopa versus levodopa/carbidopa/entacapone (LCE) versus standard levodopa monotherapy in patients with advanced PD and motor fluctuations in the US., Methods: A 2-year stochastic Markov model was utilized to examine the cost effectiveness of treatments of advanced PD. The model assumed that patients transition health status every 4 months. Transition probabilities, including uncertainties, were estimated from clinical trial data. Medical costs, daily drug costs and utility weights were obtained from published literature., Results: Over 2 years, all therapy options showed greater effectiveness than levodopa alone. Rasagiline+levodopa and LCE were cost saving from a payor perspective, while entacapone+levodopa was cost saving from a societal perspective. Mean benefits over 2 years were 0.12 (90% credibility interval [CI] 0.07, 0.18) additional quality-adjusted life-years (QALYs) for rasagiline+levodopa, entacapone+levodopa and LCE, 5.08 (90% CI 3.87, 6.28) additional months with

Maintenance of symptom control in Parkinson's disease (PD) requires continuous titration of medication and addition of multiple therapies over the course of the disease. Adherence to medication is vital to symptom control and key to maximizing the efficacy of existing therapies. However, adherence is compromised by a variety of factors, including motor symptoms, complex dosing regimens, multiple medications, and lack of patient/physician awareness of the impact and prevalence of suboptimal adherence. This retrospective, longitudinal cohort study assessed the prevalence of suboptimal adherence [measured as the medication possession ratio (MPR)] to PD medications, and its impact on the worsening of PD symptoms (measured as increase in monotherapy dose, augmentation of therapy, PD-related emergency department visit, or hospitalization), in a Medicare Health Maintenance Organization population in the United States. Irrespective of the MPR threshold chosen, a high percentage of patients were categorized as suboptimally adherent to their PD medications, and patients with suboptimal adherence to their PD medications had higher risks of worsening of PD symptoms, compared with those who were adherent. Increased awareness of both the magnitude and impact of suboptimal adherence to PD medications, coupled with dosage simplification and a unified effort by healthcare professionals and patients, may improve adherence to PD medications and ultimately improve symptom control., (2007 Movement Disorder Society)

Objective: To examine the use and economic cost of antiparkinsonian agents during the medication management of patients diagnosed with schizophrenic disorders in a naturalistic healthcare setting., Design: Cross-sectional retrospective analysis of 1-year (1999) administrative data from a large managed care organization., Patients and Methods: Patients were 1938 adults who were treated for a schizophrenic disorder. Monthly per patient utilization rate and cost of antiparkinsonian agents, and the proportion of the total psychiatric medication costs attributed to the antiparkinsonian agents, were compared across antipsychotic medications (typical, atypical, olanzapine, risperidone), age, sex, and diagnostic subtype., Results: About one third (39%) of the patients were treated with typical antipsychotics only, and half of them (51%) received antiparkinsonian agents. Those treated with atypical antipsychotics only (41%) were considerably less likely to receive antiparkinsonian agents (25%), and the rate of use differed by atypical type such that risperidone-treated patients were more likely to receive antiparkinsonian agents than those treated with olanzapine. Lower utilization rates of antiparkinsonian agents were also found among patients age 75 years or older, and among those diagnosed with a schizoaffective disorder. Average monthly per patient cost of antiparkinsonian agents was 3.0 dollars, constituting 2.6% of the monthly expenditure on all psychiatric medications., Conclusions: Adjunctive use of antiparkinsonian agents differs widely among patients who are treated with typical or atypical antipsychotic drugs, and differs between types of atypical antipsychotics. The choice of atypical antipsychotics that have a lower liability for extrapyramidal symptoms may assist in optimizing the long-term functional outcomes of schizophrenia patients.

Objective: To determine the cost effectiveness of adjunctive therapy with entacapone versus standard treatment (levodopa) without entacapone for patients in the US with Parkinson's disease (PD) who experience 'off-time' (re-emergence of the symptoms of PD) while receiving levodopa., Study Design: A Markov model was used to estimate 5-year costs and effectiveness of standard treatment with and without entacapone., Methods: Probabilities, unit costs, resource utilisation data and utilities were obtained from published literature, clinical trial reports, a national database, and clinical experts. PD disability was measured using the daily proportion of off-time and Hoehn and Yahr scale scores. The analysis measured costs from a societal and third-party payer perspective, and effectiveness as gains in quality-adjusted life-years (QALYs) and years without progression to >25% off-time., Results: From a societal perspective, entacapone therapy resulted in an incremental cost of US dollars 9327 per QALY gained compared with standard treatment. Treatment with entacapone also provided an additional 7.6 months with < or =25% off-time/day compared with standard treatment. Sensitivity analyses indicated that the model is sensitive to changes in rates of improvement/deterioration of off-time, and to the number of doses per day of levodopa with adjunctive entacapone., Conclusions: The addition of entacapone to standard treatment for patients receiving levodopa who experience off-time provides additional QALYs and gain in time with minimal fluctuations. Results of this modelling exercise suggest that therapy with entacapone may be cost effective when compared with standard treatment for PD.