PT  - JOURNAL ARTICLE
AU  - Espay, Alberto J.
AU  - Norris, Matthew M.
AU  - Eliassen, James C.
AU  - Dwivedi, Alok
AU  - Smith, Matthew S.
AU  - Banks, Christi
AU  - Allendorfer, Jane B.
AU  - Lang, Anthony E.
AU  - Fleck, David E.
AU  - Linke, Michael J.
AU  - Szaflarski, Jerzy P.
TI  - Placebo effect of medication cost in Parkinson disease
AID  - 10.1212/WNL.0000000000001282
DP  - 2015 Feb 24
TA  - Neurology
PG  - 794--802
VI  - 84
IP  - 8
4099  - http://n.neurology.org/content/84/8/794.short
4100  - http://n.neurology.org/content/84/8/794.full
SO  - Neurology2015 Feb 24; 84
AB  - Objective: To examine the effect of cost, a traditionally “inactive” trait of intervention, as contributor to the response to therapeutic interventions.Methods: We conducted a prospective double-blind study in 12 patients with moderate to severe Parkinson disease and motor fluctuations (mean age 62.4 ± 7.9 years; mean disease duration 11 ± 6 years) who were randomized to a “cheap” or “expensive” subcutaneous “novel injectable dopamine agonist” placebo (normal saline). Patients were crossed over to the alternate arm approximately 4 hours later. Blinded motor assessments in the “practically defined off” state, before and after each intervention, included the Unified Parkinson's Disease Rating Scale motor subscale, the Purdue Pegboard Test, and a tapping task. Measurements of brain activity were performed using a feedback-based visual-motor associative learning functional MRI task. Order effect was examined using stratified analysis.Results: Although both placebos improved motor function, benefit was greater when patients were randomized first to expensive placebo, with a magnitude halfway between that of cheap placebo and levodopa. Brain activation was greater upon first-given cheap but not upon first-given expensive placebo or by levodopa. Regardless of order of administration, only cheap placebo increased activation in the left lateral sensorimotor cortex and other regions.Conclusion: Expensive placebo significantly improved motor function and decreased brain activation in a direction and magnitude comparable to, albeit less than, levodopa. Perceptions of cost are capable of altering the placebo response in clinical studies.Classification of evidence: This study provides Class III evidence that perception of cost is capable of influencing motor function and brain activation in Parkinson disease.CGI=Clinical Global Impression; IRB=institutional review board; PD=Parkinson disease; S&E=Schwab and England; UPDRS-III=Unified Parkinson's Disease Rating Scale, Part III