Unmet Needs for Parkinson s Disease Therapeutics
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1 Unmet Needs for Parkinson s Disease Therapeutics Coalition Against Major Diseases & FDA Workshop October 20, 2014 Caroline M Tanner MD, PhD Director, Parkinson's Disease Research Education and Clinical Center San Francisco Veteran's Affairs Medical Center & Professor in Residence, Dept. of Neurology University of California San Francisco Disclosures: Consultant for Adamas & Pfizer Pharmaceuticals
2 Topics Why Parkinson s Disease therapeutics matters Therapeutic Gaps Bridging the Gaps New approaches Continuing challenges
3 Global Burden of Parkinson s Disease Is Expected to Increase As Life Expectancy Increases World Wide 2015 AGE 60+
4 Consequently, the global burden of Parkinson s disease is expected to increase Change in number of people with Parkinson s disease in the world s most populous nations from 2005 to 2030* *Among individuals over 50 in the world s ten most and Western Europe s five most populous nations Source: Dorsey et al, Neurology 2007;68:
5 Consequences for Society Costs: Direct costs of health care Indirect costs: Loss of years worked, lost societal contributions Mental & physical costs Affects person with PD & family members, colleagues, friends
6 Mov Disord 2013
7 Can We Reduce the Burden? Education Research Advocacy Health Services Better Treatment
8 History of PD Therapy in the US 1817: Parkinson described Paralysis agitans Late 1800 s: Belladonna alkaloids as Rx 1950 s: Synthetic anticholinergics as RX Late 1960 s: L dopa 1970 s: L dopa + decarboxylase inhibitor (dci) Amantadine Bromocriptine as adjunct to l dopa 1980 s: Pergolide as adjunct to l dopa Withdrawn 2007 Sustained release l dopa/dci Selegiline as adjunct to l dopa 1990 s: 1997 Pramixpexole (mono, adjunct) 1997 Ropinirole (mono, adjunct) 1998 Tolcapone (with l dopa/dci) Black box hepatic failure 1999 Entacapone (with l dopa/dci) 2000 s: 2004 Apomorphine s.c. (Intermittent hypomobility) 2006 Rasagaline (mono, adjunct) 2007 Rotigotine patch Recall /7 Rivastigmine oral & patch Dementia 2010 : 2012 Rotigotine patch Reintroduced? ALL BUT 1 DRUG: SYMPTOMATIC TREATMENT FOR MOTOR SYNDROME
9 Clinical Knowledge Gaps in Parkinson s Disease CLINICAL COURSE: No diagnostic test No predictor of risk (for most) No reliable marker of progression No reliable predictor of prognosis TREATMENT: No way to prevent disease No cure No way to slow disease progression Inadequate Symptomatic Treatment: Motor imperfect control of symptoms, and with side effects Nonmotor many and diverse problems, few treatments
10 Bridging the Gap
11
12 THE FIRST CHALLENGE: Defining Parkinson s Disease Langston Ann Neurol 2006 Langston, 2008
13 Striatal dopamine 100% 80% 60% 40% The Second Challenge Measuring Disease Progression At diagnosis of Motor PD: 50% neuron loss in the substantia nigra 80% striatal dopamine deficit Slow or Stop Progression of motor syndrome 20 0% PRECLINICAL Pathogenesis & clinical course of PD only partially understood PRODROMAL Prevent Symptom Onset PARKINSON S DISEASE Prevent disease features: dyskinesias, dementia
14 The 3 rd Challenge: Define Measures of Risk, Onset & Progression in Parkinson s Disease HEALTH DISEASE DISEASE OUTCOMES Markers of risk Prodromal Diagnosis Progression Genes Exposure group? Hyposmia ANS RBD Tissue*? Imaging? Clinical Post-mortem Imaging (adjunct) Tissue*? Clinical exam Tissue*? Imaging? * Blood, CSF, skin, GI (ENS), salivary gland, other? RELIABLE BIOMARKERS NEEDED!
15 PPMI The Parkinson s Progression Markers Initiative: A Prospective Biomarkers Study OBJECTIVES POPULATIONS Standardized protocols Biomarker verification studies Early Untreated PD Matched Controls Dataset/ sample collection PPMI Identify progression markers RBD Hyposmics LRRK2, SNCA PD & Families Real Time Data Sharing Imaging & Biologic markers may increase efficiency of clinical trials Frasier et al, 2010; Marek et al 2011
16 Overcoming Barriers to Success in Studies of Parkinson s Disease Slow enrollment is a major cause of delay and expense Only about 10% of persons eligible to participate in studies enroll Can changes in outcomes & study conduct speed things up?
17 Improve Outcome Measures Develop Measures Not Dependent on Motor Disease: Imaging: brain (DaTScan ), other organs Physiological measures: Tremor recording, tapping time, EEG spectral analysis Global clinical measures: self reported or examination & interview based (UPDRS, QOL) Other biomarkers: laboratory measurements of body tissues (blood, urine, CSF, saliva,biopsied tissue) FUTURE: Combinations of measures
18 Increase Enrollment & Retention In Remote Assessment Clinical Trials Telemedicine
19 BIG DATA Information from continuous monitoring Large numbers of people Universal platform Can combine w/ other info (imaging, genes) Potential Benefits: Identify patterns of disease progression Reduce the burden of clinical trial participation Identify subgroups more likely to benefit from certain interventions Provide new outcome measures?
20 Linked Clinical Trials: Repurposing The map Brundin et al, J PD 2014 Revise the map of LCT
21 THANK YOU!
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