Effect of GOCOVRI (Amantadine, Extended Release Capsules) on Gait in Parkinson's Disease

The purpose of the study is to learn about the effect of GOCOVRI (Amantadine extended release) on activity levels and measures of gait and balance quality in people with Parkinson's disease (PD) and levodopa induced dyskinesia (LID) during daily activities using body-worn sensors.

Levodopa induced dyskinesia (LID) is a symptom of Parkinson's disease for which there are limited treatment options. LID leads to reduced quality of life, increased caregiver burden and an increased risk of falls (Rascol et al., 2015, Chapuis et al., 2005). GOCOVRI™ is an extended release capsule prescription medication shown to reduce LID in people with PD (Pahwa et al., 2017, Pahwa et al., 2018). However, a number of studies have identified an increase in falls in those on the active medication study arm but not the placebo arm (13% increase in active and 7% in placebo) (Pahwa et al., 2017). In order to understand this increase in falls, comprehensive measurements of quantity of activity (gait measured in the home environment) and quality of activity (comprehensive gait characteristics that may increase risk of falls) need to be assessed in participants taking GOCOVRI™. In addition, the evidence for the effect of GOCOVRI™ on gait and balance in PD is limited (Smulders et al., 2016). This study is an open label study in which the following Aims will be studied: Aim I: Investigate the effect of GOCOVRI™ on activity levels in people with Parkinson's disease (PD) and Levodopa induced dyskinesia (LID) Hypothesis I: We hypothesize that GOCOVRI™ will result in an increase of daily activity due to improvement in LID symptoms. Primary outcome measures: Total amount of activity per day Aim II: Investigate the effect of GOCOVRI™ on comprehensive measures of gait and balance quality in people with PD with LID Hypothesis II: We hypothesize GOCOVRI™ may improve discrete characteristics of gait and balance that is evident even within the first hour of the day walking.

All participants will have gait, balance, dyskinesia assessed before and after receiving GOCOVRI (274 mg/day).

Participants will have gait and balance baseline assessment and then repeat assessment after being on full-dose of GOCOVRI for two weeks. The assessments will include measures of gait, balance and dyskinesia. Participants will also wear body-worn sensors (on wrist, feet and lumbar area) during daily-life for seven days to quantify mobility. GOCOVRI will be started at 137mg/day for two weeks and then increased to 274mg/day for two weeks. Participants will repeat baseline assessments and then decrease to a dose of 137mg/day of GOCOVRI for one week, before stopping the medication completely. All participants will receive GOCOVRI and they will know that they are on study drug. No placebo group.

Investigate the effect of GOCOVRI™ on activity levels in people with Parkinson's disease (PD) and Levodopa induced dyskinesia (LID). Body-worn sensors will be used to quantify the amount of activity each day over a week.

Using body-worn sensors will quantify the amount of activity during the first awake hour of each day over a week.

The Parkinson's Disease Quality of Life questionnaire with 39 questions (PDQ-39) reflects eight domains of quality of life (Mobility, Activities of Daily Living, Emotional well-being, Stigma, Social support, Cognition, Communication, and Bodily discomfort). Each item scores from 0 (never) to 4 (always). Sub-scale scores and a Parkinson's Disease summary index (PDSI; sum of eight subsections/8) representing the global health-related quality of life will be calculated, with higher scores representing worse quality of life. Convergent validity is very good and discriminative validity for PD severity levels has been established. The PDQ-39 will be a Patient Reported Outcome to reflect limitations to participation in community mobility.

This measure assesses the types of intensity of physical activity and sitting time that people do as part of their daily lives are considered to estimate total physical activity in metabolic expenditure (MET) minutes a week and time spent sitting. Subjects score as low, moderate, or high levels of activity categories. It will be used as a second Patient Reported Outcome to reflect the level of activity during the day.

This will be one of two assessments for Levodopa Induce Dyskinesias (LID). This scale evaluates the involuntary movements often associated with treated Parkinson's disease. There are two primary sections: Historical [Part 1 (On-Dyskinesia) and Part 2 (Off-Dystonia)] and Objective [Part 3 (Impairment) and Part 4 (Disability)]. Score ranges are 0 to 44 for Part I, 0 to 16for Part II, 0 to 28 for Part III, and 0 to 16 for Part IV,with a total score range of 0 to 104. Higher scores reflect more severe dyskinesia.

The Abnormal Involuntary Movement Scale (AIMS) is an assessment of the occurrence of tardive dyskinesia The AIMS test has a total of twelve items rating involuntary movements of various areas of the patient's body. These items are rated on a five-point scale of severity from 0-4. The scale is rated from 0 (none), 1 (minimal), 2 (mild), 3 (moderate), 4 (severe). Total score ranges from 0 to 48 with higher scores reflecting more severe dyskinesia. We will compare total scores.

Inclusion Criteria: Idiopathic Parkinson'd Disease in accordance with the United Kingdom (UK) Brain Bank Criteria Hoehn & Yahr scores of II-IV subjective report of experiencing at least 1hr/day (two, half-hour periods) of ON time with troublesome Levodopa-Induced Dyskinesia (LID) ambulation with or without aids (e.g., walker or cane) ≥30 days of a stable regimen of anti-Parkinson's medications that includes a levodopa dose administered ≥3 times daily a stable dose of levodopa throughout the study no amantadine for a minimum of 30 days prior to enrollment in the study Exclusion Criteria: neurological or musculoskeletal disorders orthostatic hypotension at screening (defined as a drop of ≥20mm mercury (HG) systolic and ≥10mm HG diastolic at 2 or 5 minutes of quiet standing after 5 minutes of supine rest) a major psychotic disorder contraindication to GOCOVRI™ at time of screening, especially renal impairment estimated by glomerular filtration rate (eGFR) < 50 ml/min/1.73 m2) as impaired renal function can increase the chances of adverse reactions to the study drug mild to severe cognitive impairment as measured by Montreal Cognitive Assessment (MoCA) score ≤ 23 concurrent use of immediate release amantadine are pregnant or plan to become pregnant an implanted deep brain stimulator

Individual participants' data will be available (including data dictionary) after de-identification and will include all data collected during the trial. The study protocol, statistical analysis plan, informed consent, clinical study report, and analytic code will all be available 3 months after study publication to 5 years after publication. This data will be shared with anyone providing a methodologically sound proposal. To gain access to the data proposals should be directed to carlsonp@ohsu.edu and requesters will need to sign a data access agreement.