Delivering a Diagnosis of Parkinson's Disease and Parkinsonism with Wisdom and Sensitivity.

Parkinson's disease (PD) is a chronic, progressive, complex movement disorder. In addition to the motor manifestations, changes in mood and cognition frequently occur. It is understandable that receiving this diagnosis can be difficult for patients and their significant others. For the clinician, delivering a PD diagnosis can be challenging and requires a comprehensive patient assessment followed by a thoughtful treatment plan. How this diagnosis is conveyed can have a long-term impact on patient outcomes such as treatment adherence, participation in decision making, understanding of PD, and satisfaction with care. Because a PD diagnosis is often complicated by uncertainty about the diagnosis itself as well as future prognosis, a sensitive patient-centered approach to care, balanced with realistic expectations, is recommended. Full disclosure, honesty, and empathy on the part of the entire healthcare team are required. This includes relevant information tailored to the patient's unique needs at the time of diagnosis as well as referrals to appropriate rehabilitation and support services. Consistent, timely follow-up of all interventions is essential. It is essential that a diagnosis of PD is properly delivered to optimize understanding of PD, treatment adherence, participation in decision making, and satisfaction with care. In this article, we provide guidance on delivery of this diagnosis based on a growing body of evidence and our >35-year collective clinical experience and work developing and utilizing pertinent, creative educational tools and comprehensive, sensitive support programs for newly diagnosed patients and their significant others. Although most of the evidence we present pertains to PD, our experience suggests it could also apply to other forms of Parkinsonism and other chronic or progressive movement disorders.

Inosine to increase serum and cerebrospinal fluid urate in Parkinson disease: a randomized clinical trial.

IMPORTANCE: Convergent biological, epidemiological, and clinical data identified urate elevation as a candidate strategy for slowing disability progression in Parkinson disease (PD). OBJECTIVE: To determine the safety, tolerability, and urate-elevating capability of the urate precursor inosine in early PD and to assess its suitability and potential design features for a disease-modification trial. DESIGN, SETTING, AND PARTICIPANTS: The Safety of Urate Elevation in PD (SURE-PD) study, a randomized, double-blind, placebo-controlled, dose-ranging trial of inosine, enrolled participants from 2009 to 2011 and followed them for up to 25 months at outpatient visits to 17 credentialed clinical study sites of the Parkinson Study Group across the United States. Seventy-five consenting adults (mean age, 62 years; 55% women) with early PD not yet requiring symptomatic treatment and a serum urate concentration less than 6 mg/dL (the approximate population median) were enrolled. INTERVENTIONS: Participants were randomized to 1 of 3 treatment arms: placebo or inosine titrated to produce mild (6.1-7.0 mg/dL) or moderate (7.1-8.0 mg/dL) serum urate elevation using 500-mg capsules taken orally up to 2 capsules 3 times per day. They were followed for up to 24 months (median, 18 months) while receiving the study drug plus 1 washout month. MAIN OUTCOMES AND MEASURES: The prespecified primary outcomes were absence of unacceptable serious adverse events (safety), continued treatment without adverse event requiring dose reduction (tolerability), and elevation of urate assessed serially in serum and once (at 3 months) in cerebrospinal fluid. RESULTS Serious adverse events (17), including infrequent cardiovascular events, occurred at the same or lower rates in the inosine groups relative to placebo. No participant developed gout and 3 receiving inosine developed symptomatic urolithiasis. Treatment was tolerated by 95% of participants at 6 months, and no participant withdrew because of an adverse event. Serum urate rose by 2.3 and 3.0 mg/dL in the 2 inosine groups (P < .001 for each) vs placebo, and cerebrospinal fluid urate level was greater in both inosine groups (P = .006 and <.001, respectively). Secondary analyses demonstrated nonfutility of inosine treatment for slowing disability. CONCLUSIONS AND RELEVANCE: Inosine was generally safe, tolerable, and effective in raising serum and cerebrospinal fluid urate levels in early PD. The findings support advancing to more definitive development of inosine as a potential disease-modifying therapy for PD. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00833690.