Innovations In Clinical Neuroscience

JAN-FEB 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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R E V I E W 21 ICNS Innovations in Clinical Neuroscience • January–February 2018 • Volume 15 • Number 1–2 Despite these advantages, price might be prohibitive, as pimavanserin costs $80/day (drug acquisition cost) for the recommended 34mg dose, whereas clozapine (exclusive of monitoring costs) and quetiapine cost $1.25 and $6.86 per day, respectively. 42,43 It is likely that many insurance companies covering the medication will restrict its use, require prior authorization for coverage, or include the medication in a high co-pay tier, given its cost. Patients with PD should be routinely monitored for the development of PDP. If PDP is detected, careful discussion with the patient and caregivers should include the possible treatment options, beginning with reductions or adjustments in PD medications. Pimavanserin appears to be a better-tolerated but possibly less efficacious treatment for PDP than clozapine. In patients unable to obtain relief with antiparkinsonian medication dose-reduction alone, it is reasonable to consider a trial of pimavanserin if the patient and provider agree that the benefits of better tolerability outweigh the higher cost. If cost is a significant obstacle or pimavanserin fails, then they might consider a trial of clozapine. SUMMARY Though early trials failed to show significant improvement in the primary efficacy outcome, after adjustment in trial design, particularly to blunt placebo response and measure a primary outcome more specific to symptoms associated with PDP, the pivotal Phase III study ACP-103-020 showed pimavanserin effective in improving PD psychosis. Throughout the clinical trial program, pimavanserin appeared safe and well-tolerated, particularly with respect to its lack of deleterious effects on motor function. Given that pimavanserin boasts the first FDA-approved indication for treatment of PDP, has the most data in well-conducted trials of PDP patients, and appears safer and better tolerated than current alternatives, pimavanserin is likely to assume a significant role in the treatment of PDP. While past studies of clozapine indicate it might provide similar or greater improvement in PDP, pimavanserin is likely to produce fewer AEs and require less monitoring. Future prospective studies directly comparing pimavanserin to alternative therapies are needed to identify the most ideal treatment for PDP. REFERENCES 1. Pringsheim T, Jette N, Frolkis A, Steeves TDL. The prevalence of Parkinson's disease: a systematic review and meta-analysis. Mov Disord. 2014;29(13):1583–90. 2. Martinez-Martin P, Rodriguez-blazquez C, Forjaz MJ, et al. Neuropsychiatric symptoms and caregiver's burden in Parkinson's disease. Parkinsonism Relat Disord. 2015;21(6):629–34. 3. Kalia LV, Lang AE. Parkinson's disease. 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