"Off" time is when Parkinson's symptoms — motor and/or non-motor — return or worsen between medication doses. Not everyone experiences "off" time, but it is more common the longer you live with Parkinson’s, the longer you take Parkinson's medications and the higher the dose of medication.
Doctors and researchers use the term "off" in Parkinson's care and clinical trials, but people with Parkinson's may be less familiar with this term or what it means for them. Understanding "off" time can help you better manage Parkinson's, in partnership with your care providers.
Ask the MD: In Conversation about Parkinson's "Off" Time with MJFF Board Member Jeff Keefer
Movement disorder specialist Rachel Dolhun, MD, DipABLM, talks with MJFF Board Member Jeff Keefer, who was diagnosed with Parkinson's disease (PD) in 2007, about managing “off” time. This excerpt is from a 2020 Ask the MD video.
Understanding “Off” Time
“Off” time may occur at different times and in different ways. It might happen in the morning, before the first dose of medication. Or it can happen during the day, between scheduled doses of medication. (This is called “wearing off.”) It may even happen unexpectedly or unpredictably. “Off” time can come on gradually or suddenly.
Because everyone’s Parkinson’s is unique, “off” time varies from person to person. Examples of “off” could include:
- stiffness and foot cramping, known as dystonia, often in the morning;
- a gradual return of tremor and feeling of anxiety before the next dose of medication;
- unpredictable, sudden episodes of difficulty moving.
To help you and your doctor better understand your “off” time, it may be helpful to keep a log for a few days or weeks. Track your symptoms, how long they last, how and when they come on (slowly or suddenly, for example), along with when you take medication. This might show patterns and potential triggers that can help guide treatment.
"My 'off' episodes are extremely variable...
Sometimes I feel my medications slowly draining out of me, and sometimes it feels like a switch has flipped, shutting me down almost instantly. One constant: I always seem to turn off in the airport security line!”
– Margaret Sheehan of McLean, Virginia, diagnosed in 2004
Managing “Off” Time
There are several options for managing “off” time.
Timing Medications
If you experience “off” time, you may want to first look at how you take medication. Missing or skipping doses can contribute to “off” time. Taking levodopa with high-protein meals also may lead to “off.” This is because levodopa and protein are absorbed in the same part of the intestines, so your body may absorb less medication. If your levodopa seems to wear off before the next dose, takes longer to kick in or sometimes does not work at all, try taking it 30 minutes before or 60 minutes after a high-protein meal. Or, if possible and with the guidance of your doctor and dietitian, consider saving most of your protein for nighttime to avoid this interaction during the day.
Adjusting or Adding Medications
If you still experience “off,” you and your doctor may want to adjust your medications or add new ones. This may include taking higher or more frequent doses of levodopa or adding medication that helps levodopa last longer.
Using On-Demand Therapies
You might also consider a fast-acting “as needed” or on-demand therapy—such as medications that can be inhaled (breathed in) or injected (under the skin). These can quickly and temporarily reverse unexpected “off” time. These therapies are taken only as needed, in addition to scheduled daily medication.
Continuous and Long-Acting Options
Switching to alternative medication formulations, like longer-acting pills or continuous infusions under the skin or into the gut, may be other options. Surgical interventions like deep brain stimulation or focused ultrasound might also provide symptom relief for some people.
You and your doctor will work together to find the best approach for you, taking your unique symptoms and the pros and cons of each treatment into account.
Resources to Learn More
Listen to Our Podcast
Our panel of experts discusses "Parkinson’s “Off” Time: What It Looks Like, and How to Manage It."
Learn the Language of Parkinson’s
Doctors define “off” time and other common Parkinson’s terms.
Choosing the Right Therapy
What should you know when considering a new medication?
This resource was brought to you with support from Amneal Pharmaceuticals and Merz Therapeutics. Partner support allows us to furnish high-quality educational content to the Parkinson’s community while allocating donor dollars to high-impact research. The Michael J. Fox Foundation is solely responsible for the content on this page.
All medical information is for general information purposes only. The Michael J. Fox Foundation has a policy of refraining from advocating or endorsing any drug therapy, course of treatment, specific company or institution. Care and treatment decisions should be made in consultation with a physician or qualified medical professional.