Game-changers in Parkinson’s, chronic polyneuropathy, MS, and more

Welcome to the first issue of the MDLinx Weekly Neuro Brief!

We’ve searched high and low to gather the most vital neuro news so you don’t have to. Tell us what you think or if there’s something we missed so we can include it in our next issue.

Don’t forget to check back every Friday to stay updated on the latest from around the world!

Flashback Friday

At this time 20 years ago, researchers identified neuromyelitis optica (NMO) as a disease state that is separate and distinct from multiple sclerosis.  The seminal study on which this classification was based was published in 1999 by Wingerchuk, et al in Neurology. This rare condition is characterized by myelitis and optic neuritis. In 2004, Lennon, et al made their groundbreaking discovery of a novel, pathogenic autoantibody (NMO-IgG or AQP4-Ab) as a specific marker of NMO, which distinguished it from multiple sclerosis. Pretty neat, huh?

Novel Diagnostics

In mid-September, researchers validated the utility and value of the Erasmus Polyneuropathy Symptom Score (E-PSS) for screening patients for the presence of chronic polyneuropathy. There are currently no symptom questionnaires for chronic polyneuropathy for the screening of a lower-risk population. Such a questionnaire would be valuable in screening in an outpatient clinic or primary care setting. E-PSS had good performance and provided a valid, accurate, six-item score—based on the presence and frequency of six different symptoms—that helped assess chronic polyneuropathy. The most frequently reported symptoms in patients with polyneuropathy were numb and tingling feet.

Later in the month, in a study in Alzheimer’s and Dementia, researchers  found that unique gait signatures may be proxy measures of disease-specific pathology in patients with Alzheimer disease and Lewy body disease. Researchers assessed 16 different gait characteristics in 5 domains: pace, rhythm, variability, asymmetry, and postural control. They found that patients with Lewy body disease had more asymmetrical and variability impairments compared with patients with Alzheimer disease. Both groups had greater impairments in pace and variability compared with controls.

“This supports the current theory that gait may act as a proxy for neuropathology, as gait-cognition relationships are different between subtypes, and more asymmetrical gait in Lewy body disease may reflect more asymmetrical neurodegeneration,” concluded the researchers.

In another study, published in Radiology, researchers discovered that atrophied brain lesion volume is the only marker from MRI scans that can accurately predict which patients with multiple sclerosis (MS) will progress to the most severe form of the disease. Routine care of patients with MS involves regular MRI scans, which physicians can monitor for the development of new lesions and increased atrophy. In their study, researchers concluded that the volume of atrophied brain lesions may be a valuable marker to predict patients’ conversion from the relapsing-remitting stages of MS to secondary progressive stages. This can be accomplished with a pair of simple MRI scans.

Novel Treatments

Good news for patients with Parkinson disease: In August, the FDA approved istradefylline, an oral adenosine A2A receptor antagonist, as an adjunctive therapy to levodopa/carbidopa for patients experiencing “off” episodes, or instances of worsened tremors and walking difficulties. This is the first approved drug of its kind, and will likely see significant improvement in quality of life for these patients.

Feeling shaky? Researchers are testing a new wearable device for the treatment of hand tremors in patients with Parkinson disease. A new wrist neuromodulator, Cala Therapy (Cala TrioTM), is the only individualized, non-invasive therapy for essential tremor, and helped patients achieve significant reductions in hand tremors in a new study. Researchers presented results from the PROSPECT study at the International Congress of Parkinson’s Disease and Movement Disorders. After wearing the device for two 40-minute sessions each day for 3 months, 68% of patients had significant improvements in hand tremor after 3 months as measured by the Activities of Daily Living assessment scale.

Researchers are making headway with drug approvals. Eculizumab, a terminal complement pathway inhibitor, can now be prescribed for the treatment of refractory myasthenia gravis. The drug was studied in an open-label extension trial in 120 patients. Eculizumab was administered every 2 weeks for up to 3 years. The incidence of exacerbations was 75% lower compared with the baseline 1-year pre-study rate. In addition, functional gains were maintained, and there were no new safety concerns. Researchers cautioned, however, that because of this agent’s potential for “adverse events of special interest,” it should only be considered in carefully selected patients with refractory or severe disease, or in those who are dependent on maintenance IV immune globulin or plasma exchange.

Medicine can be a headache sometimes. If you or a patient frequently suffer from migraines, luckily, rimegepant, a single-dose investigational agent, was found to be superior to placebo in the treatment of migraine, according to a study published in the New England Journal of Medicine, which was also presented at the annual meeting of the American Headache Society. Rimegepant is an oral calcitonin gene-related peptide receptor antagonist. Significantly more migraineurs treated with rimegepant were pain-free at 2 hours and free of their most bothersome symptoms compared with those who received placebo. Rimegepant belongs to the gepants, a new class of drugs being studied for migraine. Currently, two gepants are in phase III clinical trials for the acute treatment of migraine: rimegepant and ubrogepant.

New in Patient Management

And in patient management news, physicians need to be vigilant in patients with chronic hepatitis C (CHC) because they may be at an increased risk of developing parkinsonism or Parkinson disease (PD), according to Taiwanese researchers. However, they also found that patients with CHC treated with antiviral therapy are at a decreased risk of parkinsonism or PD.

Bad news for e-cigarette users just won’t stop rolling in. The FDA has announced 120 reports of seizure or other serious neurologic symptoms, including tremors and fainting, in youth and young adults using e-cigarettes. They are investigating a potential association and have requested that healthcare providers report any cases of seizure and other neurologic events following exposure to or use of e-cigarettes.

Screen aging patients annually for memory problems, according to the American Academy of Neurology (AAN). They recommend that people aged 65 years and older be screened annually for memory problems. Thinking skills are the most sensitive indicators of brain function, and are relatively easy to test for. Even mild cognitive impairment can be an early precursor of Alzheimer disease and other forms of dementia, and may be a symptom of sleep problems, medical illness, depression, or a medication side effect. The AAN recommends that doctors measure how often they conduct annual screenings to improve their recognition of mild cognitive impairment and allow for earlier intervention. This recommendation for age and frequency of screening is the first of its kind ands is part of an AAN quality measurement set published in the September 18, 2019, online issue of Neurology.

Who said computer games were just for kids? Researchers found that a new home exercise computer gaming program (cycling) may help patients with Parkinson disease exercise regularly. According to the Parkinson’s Outcomes Project, a 10-year study involving 12,000 people in 5 countries, embarking on a regular exercise routine to incorporate at least 2.5 hours/week of exercise as soon as possible after a diagnosis of Parkinson disease can slow disease progress. In the Park-in-Shape study, participants were randomized to two groups: cycling and stretching. Cyclists were to cycle on an exercise bike with a screen and games to motivate them for 30-45 minutes three times per week for 6 months. The control group did stretching exercises. Cyclers showed significant improvements in motor ability. Results were published in The Lancet Neurology.

Guideline Updates

1. Vaccine-preventable infections and immunization in multiple sclerosis
This is an update on the 2002 guidelines on immunization and multiple sclerosis (MS) from the American Academy of Neurology. The updated recommendations include adherence to all local vaccine standards for patients with MS, and counseling patients to receive the flu vaccine each year. Initiation of treatment with immunosuppressive/immunomodulating medications is also addressed, with recommendations for pre-treatment screening for any infections—including for latent infection in high-risk patients.

2. Acute Treatment of Migraine in Children and Adolescents
This guideline update replaces those issued in December 2004. Updated recommendations include how to establish a specific headache diagnosis, specifics on the treatment of acute migraine and individualization of treatment, and counseling interventions. In particular, sumatriptan/naproxen OT are highlighted, as well as the addition of an NSAID to a triptan in order to improve pain response rates and pain-free status. Contraindications and precautions for triptan use in children and adolescents are also outlined.

3. Pharmacologic Treatment for Pediatric Migraine Prevention
Additional practice guideline update replacing those issued in December 2004 include recommendations on patient and family counseling education, initiating preventive treatment, patient monitoring, medication cessation, and the treatment of children and adolescents with concurrent mental illness.

4. Treatment of Tics in People with Tourette Syndrome and Chronic Tic Disorders
These new guidelines detail current recommendations on patient counseling, assessment and treatment of ADHD and OCD in children with tics, assessment of tic severity and treatment expectations, behavioral treatments, and the use of alpha agonists and antipsychotics. Also included are recommendations regarding the use of botulinum toxin injections for tics, cannabis-based medications, and deep brain stimulation for patients with Tourette syndrome and chronic tic disorders.

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Medical Meetings This Month:

144th Annual Meeting of the American Neurological Association (ANA) annual meeeting in St. Louis, MI, October 13-15.

Congress of Neurological Surgeons (CNS) annual meeting in San Francisco, CA, Oct 19-23.

Neuroscience 2019 in Chicago, IL, Oct 19-23.

View more upcoming Neuro meetings

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