Objective: The objective is to report unique and challenging cases, who had successful control of Parkinson’s disease (PD) symptoms with combination therapy of Deep Brain Stimulation (DBS) of bilateral subthalamic nucleus (STN) and Levodopa Carbidopa Intestinal Gel pump therapy (LCIG).

Background: DBS is a well-established treatment modality for PD patients, especially, young- onset. As the disease progresses, it becomes challenging to control the symptoms, mostly axial symptoms such as retropulsion and gait disturbances, and stimulation related side-effects. Adjunctive LCIG therapy can help control the DBS refractory symptoms.

Method: Cases from UAE and Saudi-Arabia

Results: First case is a 47-years-old male known to have young-onset PD at age of 35 years. He had progressive symptoms of rigidity, bradykinesia and tremor, started on right side which progressed to the left side, with difficulty walking. Patient had good response to dopaminergic medications and later developed fluctuations. At age 42, patient had DBS of bilateral STN with good results with improvement in motor symptoms. At age 47, patient had worsening of symptoms with prominent retropulsion, bradykinesia, foot dystonia and eventually became wheelchair-bound. Further DBS programming and uptitration of levodopa medications did not lead to significant improvement. Patient was started on LCIG treatment at rate of 6.5ml/hr with additional levodopa at bedtime and rotigotine. Patient showed excellent clinical improvement with regards to postural control and balance, with ability to ambulate independently.
Second case is a 39-year-old male known to have young-onset PD  diagnosed at the age of 33. Presented with right-hand clumsiness and tremor that progressed to involve the left side and lower limbs. Patient had levodopa responsive symptoms and developed motor fluctuations and dyskinesias. Patient had bilateral DBS of STN, with good response for 2 years. Then the patient had worsening of symptoms with the presence of gait difficulties and psychiatric symptoms not improving with medications.  Patients DBS parameters were reduced because of his psychiatric manifestations and gait difficulties but his motor symptoms got worse.  Patient had LCIG treatment at a continues dose of 5.5ml/hr with significant improvement in symptoms.

Conclusion: Combination of LCIG and DBS therapy could be considered in challenging PD patients.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/levodopa-carbidopa-intestinal-gel-in-patients-with-deep-brain-stimulation-in-parkinsons-disease-first-case-series-from-middle-east-region/