Bridging the Gap in Parkinson's: Q&A Session with an Expert
(Focus - India)
Parkinson's Disease (PD) is a neurodegenerative disorder characterized by the gradual loss of dopamine-producing brain cells, resulting in various motor and non-motor symptoms. According to the World Health Organization (WHO), the prevalence of PD has doubled in the past 25 years, underscoring the increasing importance of finding more effective treatments and interventions. While the exact causes of PD are still the subject of ongoing research, it is widely believed that a combination of genetic and environmental factors contributes to its development.
To learn more about it, we engaged in an informative conversation with Dr. Sujith Ovallath, an esteemed Neurologist with 17+ years of experience. Dr. Sujit explained the intricate nature of Parkinson's disease, from clinical diagnosis to treatment, highlighting recent breakthroughs in therapeutic approaches and the need for increased research funding within India.
Dr. Sujith Ovallath is a Senior Consultant Neurologist currently serving at Baby Memorial Hospital, Kerala, India.
Most of the time, we can look into certain symptoms and signs. Generally, the family members will say the patient is not swinging the hands on one side, and there can be rest tremors, especially the thumb moving like a pill-rolling fashion. Then there may be shoulder periarthritis, often mistaken for some other disease, which may be an early sign because as the arm swing reduces, the shoulder gets fixed, and what you get is periarthritis.
Currently, it's believed a combination of genetic changes and environmental factors may be responsible for Parkinson's Disease. However, the exact cause for the loss of nerve cells is not known . What is your opinion about why the loss of nerve cells associated with Parkinson's disease occurs?
Dr. Ovallath - As you rightly pointed out, it is not yet known. But there are several known factors. Mainly certain drugs lead to Parkinson's, anti-psychiatric drugs, and drugs used for vomiting, migraine, and vertigo. Sometimes some drugs that can increase gastric motility, like levosulpiride, have been attributed to Parkinson's; that's a large chunk of it. Then there are certain external factors like repeated blows or severe head injury. Then poisoning due to carbon monoxide, carbon disulfate, and some organophosphorus compounds can lead to Parkinson's. But in most cases, the etiologies still are not known.
Since general practitioners are often the first point of contact for patients experiencing movement-related symptoms, what are the key warning signs that they should focus on to accurately diagnose Parkinson's disease and refer to specialists?
Dr. Ovallath - Most of the time, we can look into certain symptoms and signs. Generally, the family members will say the patient is not swinging the hands on one side, and there can be rest tremors, especially the thumb moving like a pill-rolling fashion. Then there may be shoulder periarthritis, often mistaken for some other disease, which may be an early sign because as the arm swing reduces, the shoulder gets fixed, and what you get is periarthritis. If the patient doesn't have diabetes, you think of Parkinson's positively whenever you see a case of periarthritis. Another thing is this peculiar reptilian stare where the blinking rate comes down low so that you can see that the patient is staring at you always because the blink rate comes down. Then, all the other features like stiffness, turning difficulty, slowness, shuffling, and swooping forward all come later on. Initially, it is mostly reduced arm swing and rush tremor.
There are also so many drugs coming. Inhaled levodopa has been FDA-approved. The long-acting amantadine is already in the Indian market. Then apomorphine sublingual is coming; previously, it was injection. These are newer drugs. Safinamide has been in the market for a few years now.
We understand that currently, no tests can conclusively show Parkinson's disease. Do you see any recent advancements in the field of Parkinson's disease diagnosis?
Dr. Ovallath -There are tests, but most of these tests use radionuclides. So, we don't generally recommend it; we don't want to expose the patient to radioactivity unnecessarily. So, we don't generally recommend it because clinical findings itself is sufficient to make a diagnosis of Parkinson's. It may be very doubtful in some patients, especially when patients below 40 come to you with Parkinson's syndrome. We are not sure whether it is Parkinson's or something else. In such cases, we will advise functional neuroimaging like Positron Emission Tomography (PET), Single-photon emission computed tomography (SPECT), especially Fluorodopa PET scanning. But generally, we don't use it.
Talking about the CSF biomarkers, I don't know how far it is going to be useful because the specificity, even though they are very sensitive, the specificity is much less because α-synuclein in the CSF gets positive in so many other diseases also, like Alzheimer's and all. If they can find out the exact type of alpha-synuclein responsible for Parkinson's in the CSF, maybe you can find out. I think it needs to be more refined.
Doctor, what other research is being conducted in the field of Parkinson's disease therapeutics? Could you comment on some potential future treatment options that patients can expect in the near future?
Dr. Ovallath - There are also so many drugs coming. Inhaled levodopa has been FDA-approved. The long-acting amantadine is already in the Indian market. Then Apomorphine sublingual is coming; previously, it was injection. These are newer drugs. Safinamide has been in the market for a few years now. Then deep brain stimulation (DBS) treatment by directional leads (D-leads) is a new intervention. Previously, we used to stimulate with an electrode, which gives the current in the surrounding area. Now, you can direct the current so there are no side effects. That has recently come. For tremor-predominant Parkinson's focused ultrasound is now available in India.
Doctor, in light of your statement regarding the emergence of several novel drugs, what are your thoughts on their adoption in the Indian market? Are these drugs being embraced early on?
Dr. Ovallath - Earlier, it took a few years for a drug to come to the Indian market after FDA approval. But now, maybe within one or two years, it is coming to the Indian market also. But many new drugs or treatments like the jejunal direct levodopa are not affordable to most Indian patients. When treatment comes, it is not easy for Indian patients to adopt it because they are expensive. After some time, it becomes cheaper, and then we can use it.
Apart from cost, doctor, is there any other challenge in the treatment and management of Parkinson's disease?
Dr. Ovallath - First of all, so many experimental drugs have come. But to approve it, we need all the phase one, two, and three trials. So many drugs that proceed to the first and second phases do not pass phase three trials. That's what we are usually seeing. The third phase has to be passed. So that is the important challenge.
India is slowly picking up in the research field. The central government is now giving more funds to research organizations. Most of the clinicians in India do not have time to work on these projects because they are very busy with patients. I think the government needs to find a parallel group of people interested in scientific research, especially Ph.D. and postdoctoral people in neuroscience.
How can the healthcare system and researchers work to address these challenges and improve the overall quality of care for Parkinson's patients?
Dr. Ovallath - When you compare the research facilities in India with other countries like US, UK, or Australia, I would say it is still in the primitive stage because we don't have many research labs associated with universities compared to the western world. Because where I studied, there is a big brain research center, and many people are working on various aspects of different degenerative diseases. Such things are very few in India, and private organizations are not ready to invest in this. We need more funding for such research because you may not get an immediate return.
So, what about the coming ten years? Do you see a great advancement in this field, or will it be the same?
Dr. Ovallath - India is slowly picking up in the research field. The central government is now giving more funds to research organizations. Most of the clinicians in India do not have time to work on these projects because they are very busy with patients. I think the government needs to find a parallel group of people interested in scientific research, especially Ph.D. and postdoctoral people in neuroscience. That is what all Western countries have done. They have all clinical wings separated and collaborate with the research wing. That will develop in India a few years later when funding becomes more common. Tata Memorial Center is doing a lot of work in cancer research. For the research on other degenerative diseases, private funding has to come.
To conclude our session, do you have any closing statement or suggestions for Parkinson's patients and their caregivers?
Dr. Ovallath - The available drugs can improve the quality of life for 5 to 10 years. Afterward, the drugs become less effective, and if affordable, deep brain stimulation is a very good option for them. Cost is the prohibiting factor in India because the treatment costs more than ten lakhs. So, most of the patients may not be able to afford DBS. It may be more useful if some companies can develop these devices in India. That's my feeling.
Thank you so much for your time. It was great talking to you.