Highlights

So, the pendulum is sort of swinging from the use of non-L-dopa drugs initially, and there was a movement over the last 10–15 years to use medications such as dopamine agonists or MAO inhibitors in the early stages of Parkinson’s to delay the need for levodopa, but the pendulum is swinging back to introducing levodopa early, particularly when the patient’s symptoms are troublesome. So, if the patient has troublesome motor symptoms, we usually start with carbidopa/levodopa. Some people start with rotigotine, which is a little bit longer extended-release carbidopa/levodopa, but that is difficult to prescribe in the United States as the initial formulation of levodopa because most insurance companies require that the patients are first treated with carbidopa/levodopa before they are placed on Rytary.

I’m not a big believer in obinutuzumab, and this is a controversial point. Some of my colleagues do more, I don’t, I believe it’s more a Roche attempt to circumvent the patent issue of rituximab. So, obinu will have some incremental progression-free survival difference, 10 months was the difference that led to approval in a disease where you have a life expectancy of many, many years, and so that’s not much difference. The FDA approved it, but it has more side effects for sure, particularly in older people, if you give them obinutuzumab they actually have more infusion reactions and so forth.