This chart represents a single day, of a patient with PD who takes levodopa three times a day (at each *). The availability of l-dopa is shown on the y-axis. The lower bar shows a diary, as experienced by the patient: yellow is off, green is fine, red is dyskinesia. We will use this N=1 example to explain the way PSW can be used to optimize treatment.
A single dose of Levodopa,
the best and most used drug fo Parkinson's only works for a short time, usually several hours.
Disease severity determines the lowest effective l-dopa level (the line between yellow and green, min). If l-dopa levels remain below this line, patients are undertreated, and usually experience their typical parkinson symptoms, so called off. This may include motor symptoms (e.g. stiffness, slowness, tremor) or non-motor symptoms ( e.g. altered mood or cognition, autonomic dysfunction).
L-dopa levels above the line between the green and the red zone, occur where patients are overtreated. They usually experience motor symptoms like dyskinesia (i.e. involuntary choreodystonic movements) or non-motor symptoms ( e.g. mania or hypersexuality).
Parkinson’s is a degenerative disease. The disease worsens over time. Therefore, medication needs to be adjusted from time to time.
This requires a tailored medication scheme.
Choosing an effective treatment strategy, benefits a lot from the ability to reconstruct a presumed model of the pharmacokinetic profile of levodopa. As shown in the example above, an approximation of the white line (the levodopa availability) can be reconstructed from the course of the fluctuating symptoms (the diary, shown at the bottom bar), and the intake times ( the 3 *).
In this case, the first of three doses is too low. It could be adjusted by increasing the first dose, or adding a soluble levodopa dose at the same time. Reduction of the third dose may reduce the occurrence of dyskinesia.
This example of 'delayed on' may also represent low intestinal levodopa uptake of the first gift, due to intake of pills together with a meal. To detect this simple but frequent cause of undertreatment, PSW therefore records both intake times, and meal times.
A 62-years-old patient has had PD for 3 years, treated with levodopa/carbidopa, three times a day.
He tells you he is quite satisfied, he functions quite well, and is fine with the current treatment schedule.
Last week he started recording his PD status using Parkinson smartwatch.
From the website he read instructions and watched the video. He tells you what he did:
A 54-years-old patient with PD tells you his life is a mess. He experiences PD as an enemy who always wins.
You ask him to record a few days using Parkinson smartwatch.
This is the resulting chart:
Looking at the on-off scores, you conclude it resembles how he describes his life. His total schedule is very unorganised. The purple little blocks indicate when pills were taken. This also appears to happen at random, whenever felt needed, or guided by ‘gut feeling’. He cannot explain exactly how he does it. But looking at the chart he agrees with you that this is not a likely way to get a consistent response.
Together you decide to change the treatment strategy, to one with more consistency. You prepare him, telling that this will not be an instant succes. Monitoring his status with the charts, enables you to adapt the treatment schedule gradually.
He will start using the Parknson smartwatch medication reminder, with a regular schedule of levodopa/carbidopa 4 times a day,