Great Debates

While there are many great debates happening this week in the UK, perhaps the most interesting happened at today’s biannual meeting of the Association of British Neurologists Movement Disorders Special Interest Group, held in the beautiful Oxford Town Hall. The opening session of the meeting was a debate between two giants of the international Parkinson’s world: Professor Donald Grosset from Glasgow, and Professor Ron Postuma from Montreal.

The topic they were debating was “Should research focus on prodromal disease prevention or improving symptomatic therapies?” Professor Grosset set out the reasons for focussing on better treatments in the complex phase of the disease – when the treatments that we have either fail to work or side effects become increasingly troublesome and diffucult to manage. He also pointed out the near-total lack of well-proven treatments for many of the non-motor aspects of Parkinson’s (a point we have laboured in previous blog posts here). He suggested that detection of the prodromal stage was hit-and-miss and that the best case scenario was that trials in this group would costs hundreds of millions of pounds which would be better served investing in treatments for people with definite Parkinson’s.

Ron Postuma countered his argument and opened with the metaphor central to preventive medicine: people are falling over a waterfall and nearly drowning in the pool below. A man is pulling them out one by one and calls to a bystander to help. The bystander walks away, but returns at the top of the waterfall to stop people from falling down in the first place. Although  this metaphor may seem simplistic, it highlights the importance of focussing on the earliest stages. He went on to simplify the drug treatment of established Parkinson’s as “playing with neurotransmitters” – and no matter how successful one might be at doing that, there is an underlying progression of brain death. To deal with that means to effect a change before disease causing cascade of events has become unstoppable – i.e. in the earliest (prodromal) stages. Finally, he highlighted the seismic changes that have occurred in medicine in the last two generations. Penicillin used to be so expensive that patients given penicillin had their urine collected, the excreted penicillin extracted and given back to the patients to make each vial go further. Wards for women with infected wombs after miscarriages who would almost inevitably succumb to their infections closed within weeks. The AIDS wards that were in most hospitals in the 70s and 80s were empty just a few years after HIV medication started being used. New treatments for advanced cancer have changed the landscape for some of these diseases (including nilotonib which is currently being trialed in Parkinson’s), and the last two years has brought these game-changing experiences to neurological diseases with drugs such as Nucinercin – effectively curing an incurable genetic condition that killed children in their first few years. The message, he said, was clear – things we now take for granted were once hard and very expensive, and for Parkinson’s there is change on the horizon.

The rest of the meeting continued with many other fascinating and useful talks from some of the leaders of British neurology, and has offered many insights and ideas that we at Predict-PD can use to help bring us closer to a robust identificaiton of prodromal Prkinson’s and therefore, another step closer to a cure.

RNR