MovementDisordersBRIEF REPORTCLINICAL PRACTICEExpert Consensus on the Use ofOn-Demand Treatments for OFF Episodesin Parkinson's Disease:A ModifiedDelphi PanelStuart H.Isoacson,MD,'Modhureeta Achari MD,2 Roongroj Bhidayasiri,MD,34 Cynthia Comella,MD,FAAN,5Jill Giordano Farmer,DO,MPH,57 Fiona Gupta,MD,Sarah Jones,MPA,MS,David Kreitzman,MD,Daniel Kremens,MD,JD,FAAN,"Simon J.G.Lewis,MBBCh,BSc,FRCP,FRACP,MD,2 Werner Poewe,MD,Eduardo Tolosa,MD,PhD,4 Cynthia Campos,MPH,5Sarah N.Gibbs,MPH,5 and Michael S.Broder,MD,MSHS5ABSTRACT:Background:On-demand treatments can treat OFF episodes in Parkinson's disease,however,there is limited information regarding when to prescribe them.Objective:Develop expert consensus to determine appropriate clinical factors for considering on-demandtreatments.Methods:Using a RAND/UCLA modified Delphi panel method,a panel developed consensus on the use of on-demand treatments for OFF episodes.Results:The panel agreed on-demand treatments were appropriate when OFF episodes were associated withgreater functional impact and interfered with basic daily activities.The panel also agreed on-demand treatmentmay be appropriate for patients with morning akinesia and/or delayed ON of first levodopa dose and >1 type ofOFF episode (eg,early morning OFF or wearing OFF regardless of frequency).Condusions Experts agreed on-demand treatment is appropriate for many patients with OFF episodes.Thegreater the functional impact of OFF episodes,the more likely experts agreed that on-demand treatment isappropriate to prescribe.Parkinson's disease (PD)is the most common neurodegenerativeattempts to optimize dose and timing.and the addition ofdisorder affecting mobility with a global prevalence of 6.1 mil-adjunctive OFF therapies.Effective,reliable,and rapid treat-lion people in 2016-a figure expected to double over the nextment of OFF episodes remain a major unmet need.generation.AsPDpro fluctutions in symptom contro!Three pharmacological approaches are typically considered.between benefit from levodopa (L-dopa)(ON)and when benefitThe first is adjusting the current oral L-dopa regimen by increas-is no longer present (OFF)are common and often persist despiteing the dose,altering dosing frequency,or trying extendedParkinson's Disease and Movnent Disorders Ceter of Boca Raton,Boca Raton,Florida,USA;2Integrated Natrology PA,Depatment of Pirysical Medicine andReabilitation,MGovem Medical School,Uniersity of Texas,Houston,Texas,USA;Chulalongkom Cente of Excdlena for Parkinson's Disease and RelatedDisorders,Departnent of Medicine,Faclty of Medicine,Cllalongkom University and King Culalongkom Memorial Hospital,Thai Red Cross Society,Bangkok,Thailand;The Acadeny of Science,The Royal Society of Thailand,Bangik,Thailand;Departnent of Nerosingery and Neumlogical Science,Rush UniersityMedical Cente,Chicago,Minis,USA;Clobal Nescene Institute,Peminglon,Na Jersey,USA;Department of Neurology,Drexel Collge f Molicine,Pliladdpia,Pernspivania,USA:Departent ofNeurology,Mount
