Parkinson's Disease
Conditions
Keywords
Parkinson, Parkinson's Disease, Deep Brain Stimulation, levodopa-carbidopa, Duodopa, continuous intrajejunal infusion
Brief summary
Both Continuous intrajejunal Levodopa Infusion (CLI) and Deep Brain Stimulation (DBS) are accepted therapies for the treatment of advanced Parkinson's disease (PD). To date, no comparative studies have been executed. The INVEST study is an open label randomised controlled trial with cost-effectiveness as primary outcome. The main clinical outcome is quality of life; secondary outcomes are motor symptoms and neurological impairments, among others.
Detailed description
Rationale: Both Continuous intrajejunal Levodopa Infusion (CLI) and Deep Brain Stimulation (DBS) are accepted therapies for the treatment of advanced Parkinson's disease (PD). As directly comparative studies are lacking, it is unknown whether one of the therapies is more effective. Besides, CLI seems to be more expensive. To determine the optimal treatment in advanced PD, a comparative study of CLI and DBS is warranted. Hypothesis: We hypothesize that CLI is a more expensive therapy in advanced PD than DBS and that the surplus in costs is not cost-effective with regard to benefits for the patient and caregivers in quality of life, PD symptoms and adverse events. Objective: To realize a cost-effective treatment strategy in advanced PD. Study design: Prospective, randomized, open label multicentre trial, with two additional patient preference treatment arms (patient preference randomized trial). Study population: Patients with PD who, despite optimal pharmacological treatment, have severe response fluctuations, dyskinesias, painful dystonia, or bradykinesia. A total of 66 patients will be randomized, at least 120 patients will be included in the patient preference arms. Intervention: Patients will be randomized to DBS or CLI. For DBS treatment, 2 electrodes will be implanted in the brain. The electrodes are connected to an implanted pulse generator, which will be placed subcutaneously in the subclavian area. For CLI treatment, a tube will be placed in the jejunum via a percutaneous endoscopic gastrostomy (PEG). This tube is connected to an external pump that delivers the levodopa-gel. Main study parameters: There are 8 specified assessment visits: at baseline, and 1 week, 3, 6, 9, 12, 24 and 36 months after start of the study treatment. The primary health economic outcomes are the costs per changed unit on the PDQ-39 (and the costs per changed QALY for the cost-effectiveness and cost-utility analyses, respectively. The EQ-5D will be applied as the utility measure. Change in quality of life (expressed in the between group difference in change from baseline to 12 months on the PDQ-39 summary index score) is the main clinical outcome. Among the secondary outcomes are functional health, complications and adverse effects, use of care and perceptions of patients and neurologists regarding both treatments.
Interventions
DRUGContinuous intrajejunal infusion of levodopa-carbidopa
Continuous delivery of levodopa-carbidopa intestinal gel through an intrajejunal percutaneous tube (Duodopa, CLI, CILI)
DEVICEdeep brain stimulation
Bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN)
Sponsors
ZonMw: The Netherlands Organisation for Health Research and Development
Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
Randomized Clinical Trial
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Idiopathic Parkinson's Disease with bradykinesia and at least two of the following signs; resting tremor, rigidity, and asymmetry; * Despite optimal pharmacological treatment, at least one of the following symptoms: severe response fluctuations, dyskinesias, painful dystonia or bradykinesia; * A life expectancy of at least two years.
Exclusion criteria
* Age below 18 years * Previous PD-neurosurgery (e.g., DBS, pallidotomy, thalamotomy); * Previous CLI (through a PEG-tube or Nasal Jejuna\| tube); * Hoehn and Yahr stage 5 at the best moment during the day; * Other severely disabling disease; * Dementia or signs of severe cognitive impairment * Psychosis; * Current depression; * Contraindications for DBS surgery, such as a physical disorder making surgery hazardous; * Contraindications for PEG surgery such as interposed organs, ascites and oesophagogastric varices, or for Duodopa; * Pregnancy, breastfeeding, and women of child bearing age not using a reliable method of contraception; * No informed consent; * Legally incompetent adults;
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Cost effectiveness in costs per changed unit on PDQ-39 | 12 months | The costs per changed unit on the PDQ-39. |
| Cost-utility in costs per changed Quality Adjusted Life Year (QALY, years) | 12 months | The costs per QALY. The EuroQol 5D-3L (EQ-5D; 5 questions, each score 1-3, providing a health state, to be translated with provided Valuation set) will be applied as the utility measure. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Motor symptoms | 12 and 36 months | Score changes from Baseline in off and on state on Movement Disorder Society's Unified Parkinson Disease Rating Scale (MDS-UPDRS part 3; 0-132, high score is more motor symptoms) |
| Motor symptoms: time in off and on-state | 12, 24 and 36 months | Change from Baseline in time in off-state, on-state without dyskinesias, on-state without troublesome dyskinesias and on-state with troublesome dyskinesias measured with motor symptom diary |
| Motor experiences of daily living | 12, 24 and 36 months | Changes from Baseline on MDS-UPDRS part 2 (Movement Disorder Society's Unified Parkinson Disease Rating Scale (MDS-UPDRS part 2; score 0-52, high score is more worse health) |
| Dyskinesia | 12 and 36 months | Change from Baseline on clinical Dyskinesia Rating Scale (CDRS; score 0-28, high score is more dyskinesia) |
| PD-medication (levodopa-equivalent dose) | 12, 24 and 36 months | Change from Baseline expressed in levodopa-equivalent dose |
| Functional health status | 12, 24 and 36 months | Change from Baseline on Amsterdam Linear Disability Score (ALDS, 29 items; 0-100, high score is high level of functional status) |
| Non-motor symptoms (Non Motor Symptom Checklist) | 12, 24 and 36 months | Changes from Baseline on Non Motor Symptom Checklist |
| Non-motor symptoms (Rotterdam Symptom Checklist | 12, 24 and 36 months | Change from Baseline on Rotterdam Symptom Checklist |
| Non-motor symptoms (SCOPA-AUT) | 12, 24 and 36 months | Change from Baseline on SCOPA-AUT (SCales for Outcomes in PArkinson's Autonomic symptoms; score 0-92, higher score is more symptoms) |
| Disability | 12, 24 and 36 months | Change from Baseline in Hoehn and Yahr stage (H&Y stage; 1-5: a higher score is more disease progression) |
| Cognitive functioning | 12 and 36 months | Change from Baseline on Parkinson's Disease Cognition Rating Scale (PD-CRS; 0-134, higher score is a result of better cognitive performance) |
| Cognitive functioning Mattis | 12 and 36 months | Change from Baseline in Mattis Dementia Rating score (score 0-144, higher score is better cognitive function) |
| Neuropsychologic functioning BNT | 12 and 36 months | Change from Baseline in Boston Naming Test (range 0-30, higher is better) |
| Neuropsychologic functioning Letter Fluency | 12 and 36 months | Change from Baseline in Letter Fluency (score 0-100, higher is better) |
| Neuropsychologic functioning WAIS IV | 12 and 36 months | Change from Baseline in WAIS IV (Wechsler Adult Intelligence Scale IV - subsection similarities; score 0-36, higher is better) |
| Neuropsychologic functioning Reading | 12 and 36 months | Change from Baseline in Dutch Reading Test (0-100, higher is better) |
| Neuropsychologic functioning Word Test | 12 and 36 months | Change from Baseline in 15 word test (0-75, higher is better) |
| Neuropsychologic functioning Memory | 12 and 36 months | Change from Baseline in Rivermead Behavioral memory test (subsection stores; score 0-42, higher is better) |
| Neuropsychologic functioning Trail making | 12 and 36 months | Change from Baseline in Trail making test (score 10-500, higher score is longer time, i.e. worse score) |
| Neuropsychologic functioning Color Word | 12 and 36 months | Change from Baseline in Stroop Color Word Test (score 10-1000, higher is better) |
| Neuropsychologic functioning Line Orientation | 12 and 36 months | Change from Baseline in Judgement of line orientation (score 0-30, higher is better) |
| Neuropsychologic functioning Clock | 12 and 36 months | Change from Baseline in Clock construction (score 0-14, higher is better) |
| Psychiatric disease | 12 and 36 months | Change from Baseline in Mini International Neuropsychiatric Interview |
| Apathy | 12, 24 and 36 months | Change from Baseline in Starkstein's Apathy Scale (SAS; score 0-42, high score is more signs of apathy) |
| Compulsive Disorders | 12, 24 and 36 months | Change in presence of Compulsive Disorder from Baseline assessed with Parkinson's Disease Impulsive-Compulsive Disorders Questionnaire (QUIP, utilizing established thresholds) |
| Anxiety | 12 and 36 months | Changes from Baseline on Hamilton Anxiety Scale (HAM-A; 0-56, high score is worse outcome) |
| Depression | 12 and 36 months | Change from Baseline on Hamilton Depression Rating Scale (HDRS; 0-68, higher score is worse outcome) |
| Complications and description of complications | 12, 24 and 36 months | Number of participants with complications and description of these |
| Suicidality | 12 and 36 months | Changes from Baseline on Columbia Suicide Severity Rating Scale (range 0-25, higher score is worse outcome) |
| Adverse effects | 12, 24 and 36 months | Number of participants with adverse effects and description of these |
| Stopping allocated treatment | 12, 24 and 36 months | Number of participants who stopped treatment |
| Treatment failure | 12, 24 and 36 months | Number of participants with treatment failure |
| Treatment cross-over | 12, 24 and 36 months | Number of participants with treatment cross-over |
| Patient satisfaction | 12, 24 and 36 months | Descriptive questionnaire, no scale applied, descriptive statistics |
| Quality of life (on PDQ-39) | 12, 24 and 36 months | Changes from Baseline on Parkinson's Disease Questionnaire-39 (PDQ-39; score 0-100, higher score is lower quality of life) |
| Medical costs | 12, 24 and 36 months | Calculation of the total costs in euro by means of iMCQ (iMTA Medical Consumption Questionnaire) |
| Non-medical care costs | 12, 24 and 36 months | Calculation of the total costs in euro by means of iPCQ (iMTA Productivity Cost Questionnaire) |
| Caregiver burden | 12, 24 and 36 months | Descriptive questionnaire, no scale applied, descriptive statistics |
| Patients attitude to treatment | 12, 24 and 36 months | Change from Baseline on Patient Reported Outcome Scale (range 0-128, high score is worse outcome) |
| Quality of life (on EQ-5D) | 12, 24 and 36 months | Change from Baseline on EuroQol 5D-3L (EQ-5D; 5 questions, each score 1-3, providing a health state, to be translated with provided Valuation set) |
Countries
Netherlands
Outcome results
None listed