Transcript Deep Brain Stimulation Therapy for Parkinson’s Disease

Deep Brain Stimulation
Therapy for Parkinson’s
Disease
Perry C.
Benefiting from DBS Therapy since 2007
Motor Fluctuations and Dyskinesias Decrease Quality of
Life for People with Parkinson’s Disease1
• In the United States more than 1 million people living with
Parkinson’s disease (PD)2
• Levodopa generally provides smooth and stable benefits for
up to 5 years3
• After this period, patients may experience increasingly
troublesome and unpredictable motor fluctuations and
dyskinesias3
1. Adler, CH. Relevance of motor complications in Parkinson’s disease. Neurology. 2002;58(Suppl 1):S51-S56.
2. National Parkinson’s Foundation (www.parkinson.org/Page.aspx?pid=225) accessed site, Dec. 3, 2009.
3. Melamed E, Ziv I, Djaldetti R. Management of Motor Control Complications in Advanced Parkinson's Disease.
Movement Disorders, 2007;22(Suppl. 17)S379-S384.
Treating motor fluctuations and dyskinesias
requires moving beyond standard dopamine
replacement therapy3
• The delayed “on,” wearing off, and dose failure of levodopa
may be due to its impaired absorption, short half-life, and the
loss of striatal dopamine storage capacity3
• When drugs become less reliable, Medtronic DBS Therapy
(Deep Brain Stimulation) should be considered to achieve PD
treatment goals
• According to the American Academy of Neurology (AAN),
“10% to 20% of people with PD may be eligible for surgical
treatments”4
3. Melamed E, Ziv I, Djaldetti R. Management of Motor Control Complications in Advanced Parkinson’s Disease.
Movement Disorders. 2007;22(Suppl. 17)S379-S384.
4. AAN Guidelines for patients and their families: medical and surgical treatment for motor fluctuations and dyskenisias in
Parkinson’s disease. April, 2006.
How Does Medtronic DBS Therapy Work?
• One or 2 leads are implanted to
deliver electrical stimulation to
parts of the brain involved in
movement control, including the
globus pallidus (GPi) or
subthalamic nucleus (STN)
• Current delivered by the lead is
believed to disrupt and modulate
abnormal motor circuit activity in
the brain caused by PD, thereby
smoothing out motor function
• The exact mechanism of action
isn’t completely understood
Medtronic DBS Therapy with Medications Provides
an Additional 5.1 Hours of “On” Time to Smooth
Out Motor Function Throughout the Day5
Without DBS Therapy
With DBS Therapy
5. Activa Therapy Clinical Summary, 2009.
* This chart is for illustrative purposes and does not
reflect actual “on” or “off” time.
5.1 Hours of Additional “On” time Without Dyskinesias
Compared to Best Medical Therapy (BMT)5
• Medications were
reduced 25% on average
for patients receiving
DBS Therapy5
• Results from prospective
multicenter randomized
control trial of patients
with advanced PD5
Additional “On” Time Without Dyskinesias5
DBS Therapy
+ BMT
(n=108)
5.1
hours
BMT Alone
(n = 118)
0 hours
0
1
2
3
4
5
6
Mean Additional Hours of “On” Time Without
Dyskinesias
*Results were at 6 months post implant
versus baseline.4
P<0.001
Best Medical Therapy Defined
Patients who received BMT were managed actively by movement disorder
neurologists. Patients received state-of-the-art care, including the active
management of medications and non-pharmacological therapy (e.g., physical
occupational, and speech therapy) as needed to achieve best symptom control.
5. Activa Therapy Clinical Summary, 2009.
Percent Improvement in “Off” Medication UPDRS
Motor Scores Compared with Pre-DBS Therapy Baseline6
In a Separate Study, DBS Therapy Was Shown to
Maintain Symptom Improvements After 5 Years6
100
1 Year (n = 43)
3 Years (n = 42)
83%
80
73%
74%
71%
75%
5 Years (n = 42)
75%
63%
60
52%
49%
40
20
0
Rigidity
Tremor
Akinesia
p < 0.001 5 years after surgery versus baseline
6. Krack R, Batir A, Van Blercom N, et al. Five-Year Follow-up of Bilateral Stimulation of the
Subthalamic Nucleus in Advanced Parkinson’s Disease. N Engl J Med. 2003;349:1925-34.
Proven Safety Profile
• Improvements in MRI imaging, stereotactic equipment and
software, and patient selection have all helped advance
DBS Therapy since the FDA first approved it in 1997
• Although there was a significantly higher incidence of serious
adverse events observed in patients receiving DBS Therapy,
99% of serious adverse events were resolved by 6 months5
• The majority of serious adverse events* with DBS Therapy
are procedure related and temporary5
5. Activa Therapy Clinical Summary, 2009.
* A serious adverse event was defined according to FDA regulations as any event
that: results in death, is life-threatening, results in prolonged or new hospitalization,
results in disability or congenital anomaly/birth defect, or requires medical or
surgical intervention to prevent one of the above outcomes.
What are the Risks Associated
with DBS Therapy?
• There are risks to consider with DBS Therapy, as is the case with
any brain surgery. Be sure to discuss the possible surgical
complications and side effects with patients.
• Risks of brain surgery may include serious complications such as
coma, intracranial hemorrhage, seizures and infection. Some of
these risks may be fatal.
• Possible device complications include infection, problems with
lead/extension connector positioning, parts wearing through the
skin, or an interruption in therapy because of mechanical or
electrical problems. Any of these situations may require additional
surgery or cause symptoms to return.
• Some side effects associated with the stimulation may include
worsening of tremor or speech and language impairments. Typically,
these side effects are not permanent and can be resolved by
adjusting stimulation parameters. Depression, suicidal thoughts, and
suicide, have also been reported. Occurrence of “fall” has been
observed in patients with Parkinson’s disease.
Benefits of Adding Medtronic
DBS Therapy
Medications Alone Medtronic DBS Therapy
0 hours of additional “on” time5 5.1 hours additional “on” time without
troubling dyskinesias*
Unpredictable More predictable
Dyskinesias and nonmotor Medication reductions may lead to
side effects fewer drug-induced side effects
Pulsatile delivery Continuous delivery
GI absorption required No GI absorption
Must cross blood-brain barrier Targeted and direct
Dosing compliance challenges Simplified medication regimen may
be possible
*Mean results; DBS is adjunctive to medications.
5. Activa Therapy Clinical Summary, 2009.
When Is Medtronic DBS Therapy Appropriate?
• Should be considered when the patient, despite optimal
medical therapy, reaches a stage where the daily burden of
PD begins to cause significant interference with:
•
•
•
•
Daily function
Occupational activities
Important leisure time pursuits
Basic activities of daily living
• Discuss each patient’s goals and expectations
to determine whether DBS Therapy is right
• Set realistic goals about the benefits of
Medtronic DBS Therapy
Medtronic DBS Therapy in the
PD Continuum of Care
Window of Opportunity
Patient is experiencing troubling
motor symptoms not effectively
controlled by medications.
• “On” time characterized by disabling
dyskinesias (or other nonmotor side
effects)
OR
• “Off” time characterized by disabling
tremor, rigidity, or akinesia/bradykinesia
OR
• Upredictable “on/off” motor fluctuations
OR
• Medication-resistant tremor
In order to obtain maximum benefit, PD patients must be referred
at the optimal time, or during a “window of opportunity” when
DBS therapy may be most effective.
Medtronic DBS Therapy Exclusion Criteria
•
•
•
•
No longer responsive to dopaminergic medication
Severely disabled even in the best “on” state
Medical conditions that prevent surgery
Onset of frank dementia
Medtronic DBS Patient Referral Advisor
• A tool that creates a patient
“appropriateness” profile for
DBS Therapy based on
5 absolute criteria and
7 relative criteria
• Clinical criteria and
appropriateness ratings were
developed by an expert
panel of neurologists
• Software can be downloaded
at:
www.medtronic.com/dbsreferraladvisor
Patient Management
• Establish a partnership with
an implant center to
manage postimplant patient
care, which involves:
-Programming
-Medical management
Device Programming
• Initial device programming: Identifying and
programming optimal stimulation
parameters during the first several months
• Maintenance device programming:
Titrating stimulation as needed over time
• Patient programming is reimbursed
Innovative Programming Software
• Medtronic has developed technology
to make device programming easier
Features include:
• A step-by-step process that provides
a systematic approach to
programming
• The ability to capture, store and sort
patient data in the device
• Functionality that maximizes
therapeutic response and device
longevity
Neuromodulation Therapies: Present
• Today, more than 500,000 patients globally have received
Medtronic neuromodulation devices.6
• DBS Therapy continues to be the fastest growing treatment
option for people suffering from movement disorders.
• More than 80,000 patients globally have been
treated with Medtronic DBS Therapy
6. Medtronic, Inc. data on file.
Neuromodulation Therapies: Future
• The future of neurology will
include the integration of
device-based neuromodulation
treatment into the management
of the most common neurological
disorders
Medtronic Neuromodulation Therapies
PRESENT
Parkinson’s Disease
Essential Tremor
Dystonia*
Obsessive-Compulsive Disorder*
Chronic Pain (Opioid)
FUTURE
Intracerebroventricular (ICV) Applications
Depression
Chronic Migraine (ONS)
Chronic Pain (Nonopioid)
Malignant Pain
Chronic Pain
Spasticity
Urinary Incontinence and Retention
*Humanitarian Device: The
effectiveness of this device for
the treatment of dystonia or
obsessive-compulsive disorder
has not been demonstrated.
Medtronic: The Leader in DBS Therapy
Medtronic is committed to advancing the science of
neuromodulation through:
• Product innovation
• Education
• Procedure support
• Innovative clinical research
Product Innovation
• Medtronic continues to offer new products such as
– Activa® PC: The next generation primary cell
neurostimulator
– Activa® RC: The first rechargeable neurostimulator
for DBS Therapy
• New programming platform provides
step-by-step guidance and advanced
device programming options
Innovative Clinical Research
• Medtronic has sponsored numerous studies to evaluate the
safety and efficacy of Medtronic DBS Therapy for current and
future indications
• More than 2,000 clinical papers have been published on DBS
Therapy
Approved Indications for DBS Therapy
• Parkinson’s disease (FDA approved in 2002)
• Essential tremor (FDA approved in 1997)
– AAN Guidelines state that unilateral DBS resulted in a
significant (60% to 90%) reduction of contralateral limb
tremor.7
– DBS Therapy improves activities of daily living in patients
with ET.5
• Dystonia (FDA approved HDE* in 2003)
• Obsessive-compulsive disorder (FDA approved HDE* in
2009)
– The first psych indications approved for DBS
* Humanitarian Device: The effectiveness of this device for the treatment of dystonia or obsessive-compulsive
disorder has not been demonstrated.
5. Activa Therapy Clinical Summary, 2009.
7. Zesiewicz TA, Elble R, Louis ED, et al. Practice paramater: therapies for essential tremor: Report of the Quality
Standards Subcommittee of the AAN. Neurology. 2005;64:2008-2020.
Medtronic DBS Therapy and Your Practice
Step 1. Partner with your local implanting team.
• Establish referral processes and communications.
• Establish postimplant patient management roles.
Step 2. Identify appropriate patients.
• Attend a Medtronic education program to learn more about
appropriate patient selection.
• Use the DBS Therapy Patient Referral Advisor to confirm
appropriateness for patient referral.
Medtronic DBS Therapy and Your Practice
(continued)
Step 3. Discuss DBS Therapy with patients and their caregivers.
• Discuss patients’ goals with them.
• Educate patients about the benefits and risks of DBS
Therapy.
• Set appropriate expectations.
Step 4. Refer appropriate patients for DBS Therapy.
Brief Disclosures
Medtronic DBS Therapy for Parkinson’s Disease, Tremor, and Dystonia: Product technical manual must be reviewed prior to use for detailed disclosure. *
Indications:
Medtronic DBS Therapy for Parkinson’s Disease: Bilateral stimulation of the internal globus pallidus (GPi) or the subthalamic nucleus (STN) using Medtronic DBS Therapy for
Parkinson’s Disease is indicated for adjunctive therapy in reducing some of the symptoms of advanced, levodopa-responsive Parkinson’s disease that are not adequately
controlled with medication.
Medtronic DBS Therapy for Tremor: Unilateral thalamic stimulation using Medtronic DBS Therapy for Tremor is indicated for the suppression of tremor in the upper
extremity. The system is intended for use in patients who are diagnosed with Essential Tremor or Parkinsonian tremor not adequately controlled by medications and where
the tremor constitutes a significant functional disability. The safety or effectiveness of this therapy has not been established for bilateral stimulation.
Medtronic DBS Therapy for Dystonia: Unilateral or bilateral stimulation of the internal globus pallidus (GPi) or the subthalamic nucleus (STN) using Medtronic DBS Therapy for
Dystonia is indicated as an aid in the management of chronic, intractable (drug refractory) primary dystonia, including generalized and segmental dystonia, hemidystonia, and
cervical dystonia (torticollis), for individuals 7 years of age and older.
Contraindications: Contraindications include patients who will be exposed to MRI using a full body radio-frequency (RF) coil or a head transmit coil that extends over the
chest area, patients who are unable to properly operate the neurostimulator, or for Parkinson’s disease and Essential Tremor, patients for whom test stimulation is
unsuccessful. Also, diathermy (e.g., shortwave diathermy, microwave diathermy or therapeutic ultrasound diathermy) is contraindicated because diathermy's energy can be
transferred through the implanted system (or any of the separate implanted components), which can cause tissue damage and can result in severe injury or death. Diathermy
can damage parts of the neurostimulation system.
Warnings/ Precautions/Adverse Events: There is a potential risk of tissue damage using stimulation parameter settings of high amplitudes and wide pulse widths. Extreme
care should be used with lead implantation in patients with a heightened risk of intracranial hemorrhage. Do not place the lead-extension connector in the soft tissues of the
neck. Placement in this location has been associated with an increased incidence of lead fracture. Theft detectors and security screening devices may cause stimulation to
switch ON or OFF, and may cause some patients to experience a momentary increase in perceived stimulation. Although some MRI procedures can be performed safely with
an implanted DBS System, clinicians should carefully weigh the decision to use MRI in patients with an implanted DBS System. MRI can cause induced voltages in the
neurostimulator and/or lead possibly causing uncomfortable, jolting, or shocking levels of stimulation. MRI image quality may be reduced for patients who require the
neurostimulator to control tremor, because the tremor may return when the neurostimulator is turned off.
Severe burns could result if the neurostimulator case is ruptured or pierced. The DBS System may be affected by or adversely affect medical equipment such as cardiac
pacemakers or therapies, cardioverter/ defibrillators, external defibrillators, ultrasonic equipment, electrocautery, or radiation therapy. Safety and effectiveness has not been
established for patients with neurological disease other than Parkinson’s disease or Essential Tremor, previous surgical ablation procedures, dementia, coagulopathies, or
moderate to severe depression; or for patients who are pregnant, under 18 years, over 75 years of age (Parkinson’s Control Therapy) or over 80 years of age (Tremor Control
Therapy). For patients with Dystonia, age of implant is suggested to be that at which brain growth is approximately 90% complete or above. Depression, suicidal ideations
and suicide have been reported in patients receiving Medtronic DBS Therapy for Movement Disorders, although no direct cause and effect relationship has been established.
Additionally, the abrupt cessation of stimulation for any reason should be avoided as it may cause a return of disease symptoms. In some cases, symptoms may return with an
intensity greater than was experienced prior to system implant (“rebound” effect). Adverse events related to the therapy, device, or procedure can include: stimulation not
effective, cognitive disorders, pain, dyskinesia, dystonia, speech disorders including dysarthria, infection, paresthesia, intracranial hemorrhage, electromagnetic interference,
cardiovascular events, visual disturbances, sensory disturbances, device migration, paresis/asthenia, abnormal gait, incoordination, headaches, lead repositioning, thinking
abnormal, device explant, hemiplegia, lead fracture, seizures, respiratory events, and shocking or jolting stimulation.
Humanitarian Device (Dystonia): Authorized by Federal Law for the use as an aid in the management of chronic, intractable (drug refractory) primary dystonia, including
generalized and segmental dystonia, hemidystonia, and cervical dystonia (torticollis), for individuals 7 years of age and older. The effectiveness of this device for this use has
not been demonstrated.
USA Rx only Rev 0910
Brief Disclosure – Reclaim™ DBS Therapy for OCD
Reclaim™ Deep Brain Stimulation Therapy for Obsessive-Compulsive Disorder: Product labeling must be reviewed prior to use for detailed disclosure of risks.
Indications: The Medtronic Reclaim DBS Therapy is indicated for bilateral stimulation of the anterior limb of the internal capsule, AIC, as an adjunct to medications and as
an alternative to anterior capsulotomy for treatment of chronic, severe, treatment-resistant obsessive-compulsive disorder (OCD) in adult patients who have failed at
least three selective serotonin reuptake inhibitors (SSRIs).
Contraindications: Contraindications include patients who will be exposed to MRI using a full body radio-frequency (RF) coil or a head transmit coil that extends over the
chest area, and for patients who are unable to properly operate the neurostimulator. Also, diathermy (e.g., shortwave diathermy, microwave diathermy or therapeutic
ultrasound diathermy) is contraindicated because diathermy’s energy can be transferred through the implanted system (or any of the separate implanted components),
which can cause tissue damage and can result in severe injury or death. Diathermy can damage parts of the neurostimulation system. Transcranial Magnetic Stimulation
(TMS) is contraindicated for patients with an implanted DBS System.
Warnings/precautions/adverse events:
Electroconvulsive Therapy (ECT) – The safety of ECT in patients who have an implanted deep brain stimulation (DBS) system has not been established. Induced electrical
currents may interfere with the intended stimulation or damage the neurostimulation system components resulting in loss of therapeutic effect, clinically significant
undesirable stimulation effects, additional surgery for system explantation and replacement, or neurological injury.
There is a potential risk of tissue damage using stimulation parameter settings of high amplitudes and wide pulse widths. Extreme care should be used with lead
implantation in patients with a heightened risk of intracranial hemorrhage. Do not place the lead-extension connector in the soft tissues of the neck. Placement in this
location has been associated with an increased incidence of lead fracture. Theft detectors and security screening devices may cause stimulation to switch ON or OFF, and
may cause some patients to experience a momentary increase in perceived stimulation. Severe burns could result if the neurostimulator case is ruptured or pierced. The
safety of somatic psychiatric therapies using equipment that generates electromagnetic interference (e.g., vagus nerve stimulation) has not been established. The
Reclaim DBS System may be affected by or adversely affect medical equipment such as cardiac pacemakers or therapies,
cardioverter/ defibrillators, external defibrillators, ultrasonic equipment, electrocautery, or radiation therapy. Patients should be monitored for at least 30 minutes after
a programming session, for side effects, including: autonomic effects (e.g., facial flushing, facial muscle contractions, or increased heart rate), hypomania, increased
disease symptoms, sensations such as tingling, smell, or taste. In addition, during treatment, patients should be monitored closely for increased depression, anxiety,
suicidality, and worsening of obsessive-compulsive symptoms. The safety and probable benefit of this therapy has not been established for patients with: Tourette’s
syndrome, OCD with a subclassification of hoarding, previous surgical ablation (e.g., capsulotomy), dementia, coagulopathies or who are on anticoagulant therapy,
neurological disorders, and other serious medical illness including cardiovascular disease, renal or hepatic failure, and diabetes mellitus. In addition, the safety and
probable benefit has not been established for these patients: those whose diagnosis of OCD is documented to be less than 5 years duration or whose YBOCS score is less
then 30, who have not completed a minimum of 3 adequate trials of first and/or second line medications with augmentation, who have not attempted to complete an
adequate trial of cognitive behavior therapy (CBT), who are pregnant, under the age of 18 years, and who do not have comorbid depression and anxiety. Physicians
should carefully consider the potential risks of implanting the Reclaim DBS System in patients with comorbid psychiatric disorders (e.g., bipolar,
body dysmorphic, psychotic) as the Reclaim DBS System may aggravate the symptoms. Additionally, the abrupt cessation of stimulation for any reason should be avoided
as it may cause a return or worsening (i.e., “rebound” effect) of disease symptoms. Serious adverse events related to the therapy, device, or procedure can include:
suicidality/increased depression, increased OCD/fluctuating results, intracranial hemorrhage, lead/extension failure, aggression/violent behavior, accident proneness,
irritability, death, hypomania, infection, pyelonephritis, and post-operative seizure. Adverse events related to the therapy, device, or procedure can include: coma,
paralysis, pain or discomfort at incision/implant sites, general post-op discomfort, GI symptom (post op), increased anxiety, insomnia, cognitive disturbance (clouding),
induced muscle contraction, restlessness, stimulation induced paresthesia, device migration, shocking or jolting stimulation, induced sensation of taste/smell, weight
gain, increased fatigue, upper respiratory infection, headaches, dizziness, dry mouth, itching at surgical site(s), nausea, sedation, and weight loss.
Humanitarian Device: Authorized by Federal (U.S.A) law for use as an adjunct to medications and as alternative to anterior capsulotomy for treatment of chronic, severe,
treatment-resistant obsessive-compulsive disorder (OCD) in adult patients who have failed at least three selective serotonin reuptake inhibitors (SSRIs). The effectiveness
of this device for this use has not been demonstrated.
USA Rx Only
Rev 1009