“We use various strategies to treat off time,” says Shivkumar. These may include medication regimen changes, rescue medications, diet adjustments, and deep brain stimulation.
If your Parkinson’s medication doesn’t work as well as it used to, you have a few options. “Medication adjustment is needed throughout the course of Parkinson’s, and some changes can help with off times,” says Thomas, whose treatment goal is to smooth out medication effects over the course of the day.
“[We can add] another medication to help the levodopa last longer or to work in a different way to help smooth out symptoms,” says Thomas. “Examples of these include entacapone (Comtan) or opicapone (Ongentys), rasagiline (Azilect), istradefylline (Nourianz), or amantadine (Symmetrel, Gocovri, Osmolex ER), among others.”
Instead of adding medications, your provider may recommend a change to a combination type of levodopa, like using immediate release and the extended release forms together, says Thomas.
“We can also switch to the recently approved subcutaneous infusions, which are similar to insulin pumps used in diabetes,” says Shivkumar. These pumps deliver medications at a continuous rate to minimize off periods.
Rescue Medications
Parkinson’s rescue medications can help bridge the gap until the next dose, says Shivkumar. For example, you can take Inbrija (an orally inhaled form of levodopa) up to five times a day for off episodes. This inhaled levodopa works especially well if your off episodes are unpredictable, says Barrett.
Diet Changes
As part of your treatment, your provider may recommend changes in diet or meal timing. “Some patients might experience reduced efficacy of medication if taken along with meals, as proteins can affect the absorption,” says Shivkumar, who recommends that patients take their dose one hour before or two hours after meals.
Some supplements or multivitamins, especially those high in iron or calcium, can also affect levodopa absorption, so it’s important to let your care team know if you are taking these supplements.
Surgery
If medication adjustments or dietary changes don’t resolve your off times, your provider may recommend surgery to place a tube in part of your intestine. Through this tube, you can take levodopa-carbidopa intestinal gel continually to keep your levels stable and reduce off times.
Another surgical option is deep brain stimulation, which can reduce off time in individuals whose motor fluctuations are difficult to manage with medications alone, says Barrett. Deep brain stimulation involves the placement of an electrode into the brain attached to a battery pack placed under the skin of your chest. When the electrode is on, it painlessly blocks signals that cause Parkinson’s symptoms.
