Pain in Parkinson's Disease

Treatment Prior to Safinamide

The prevailing opinion among experts in the field was that, prior to the introduction of Safinamide, the scientific literature on the management of specific pain in Parkinson's disease was characterized by a certain degree of ambiguity, i.e., it was scarce and unspecific. The recommendations were centered on the classification of pain according to its etiology (neuropathic, nociceptive, dystonic) and, primarily, on the optimization of existing dopaminergic therapy, operating under the assumption that pain was a manifestation of "OFF" periods.

Common clinical strategies include the following:

• Use of neuromodulators: Drugs such as gabapentin were frequently prescribed as a treatment option.

• Optimization of dopaminergic therapy: The objective of treatment was to stabilize dopamine levels, a process that occasionally involved the administration of agonists such as rotigotine and pramipexole.

• Local therapies: Nonsteroidal anti-inflammatory drugs (NSAIDs) and lidocaine patches were utilized for localized pain management.

• Physical therapy: This intervention was regarded as a fundamental aspect by the majority of the panelists.

• Use of botulinum toxin: Specifically for pain associated with dystonia.

• Referral to Pain Clinics: In cases that are refractory or difficult to manage.

A salient point that emerged during the discourse pertained to the panel's position on opioids. While the extant literature has recommended their use in certain cases, experts have concluded that they are used infrequently in clinical practice for this indication.

Adoption and clinical experience with Safinamide for pain

The implementation of safinamide for the management of pain occurred within two predominant scenarios:

• Initially: The medication was prescribed to patients who presented with a combination of pain and motor fluctuations, where the drug could address both problems simultaneously.

• Later: With the accumulation of experience and based on its dual mechanism of action (dopaminergic and antiglutamatergic), experts began to use it also in patients with significant pain, even in the absence of obvious motor fluctuations.

The response to treatment was described as variable, but one key and recurring observation was highlighted by the panel: "Those who respond, respond very well." While some patients exhibited no change in pain levels, those who did demonstrated significant improvement. The panel concluded that further objective and quantitative studies are necessary to measure this benefit in a standardized way. The potential for reducing other analgesic medications was found to be contingent upon the patient's individual response and the presence of comorbidities.

Dose impact: 100 mg vs. 50 mg