Objective: To compare the effect of levodopa vs deep brain stimulation on specific motor features of advanced Parkinson disease.

Background: Levodopa (LD) is the gold standard medical treatment for idiopathic Parkinson’s disease (PD), while deep brain stimulation (DBS) is an effective adjunctive treatment for motor fluctuations not responsive to oral medications. With recent improvements in LD infusion treatments including subcutaneous continuous levodopa infusion (CLI), the specific role of DBS for treatment of motor fluctuations has become less clear. Further insight into the relative effectiveness of LD and DBS for the treatment of specific motor features in PD may further inform patient selection for CLI and DBS.

Method: We analyzed 395 patients who received subthalamic nucleus (STN) DBS for PD at Washington University. We evaluated Unified Parkinson’s Disease Rating Scale part III (UPDRS-III) scores in pre-operative off-LD (OFF) and on-LD (ON), as well as post-operative on-DBS/off-LD (DBS). We performed factor analysis in each of the OFF, ON, and DBS conditions, as well as the change between ON and OFF (ON vs. OFF) and between DBS and OFF (DBS vs. OFF) for dimensionality reduction. We developed a consensus factor structure based on agreement between each condition and used this to examine the differences between treatment effects of LD and DBS. We compared scores between groups using the Wilcoxon Rank Sum Test, and corrected for multiple comparisons using Benjamini-Hochberg False Discovery Rate (FDR).

Results: Factor groups generally followed cardinal features of parkinsonism, with bradykinesia and tremor anatomically divided by upper and lower body, and axial symptoms including facial and gait-related symptoms grouped together. Lower body bradykinesia, lower body tremor, and axial symptoms significantly favored LD over DBS, while upper body tremor significantly favored DBS over LD (p < 0.05). Effects on rigidity and upper body bradykinesia were similar between treatment modalities.

Conclusion: We found that LD is more effective for the treatment of axial and leg parkinsonism (including tremor) compared with STN DBS, while DBS treats upper body tremor more effectively than LD. Further study into the relative benefit of CLI compared with DBS is warranted following FDA approval of CLI, although in patients experiencing motor fluctuations with predominantly axial and lower body symptoms a trial of CLI may be warranted prior to DBS.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/levodopa-and-dbs-produce-discordant-effects-on-parkinsonian-features/