Objective: To investigate the combined use of continuous subcutaneous foslevodopa/foscarbidopa and deep-brain stimulation in managing advanced Parkinsons Disease.

Background: Continuous foslevodopa/foscarbidopa subcutaneous (SC) infusion has been shown to significantly improve motor fluctuations. Whilst Deep Brain Stimulation (DBS) can improve motor symptoms in patients with advanced Parkinsons Disease (PD), unfortunately progressive gait, speech impairments and stimulation side-effects are not uncommon, restricting optimal symptom control. Combined use of DBS and foslevodopa/foscarbidopa has been infrequently reported in managing advanced PD.

Method: Case:

We describe a 72-year old male with advanced PD, diagnosed 11 years ago, who experienced meaningful clinical and functional improvement after initiation of adjunctive foslevodopa/foscarbidopa therapy, six years following DBS implantation for disabling tremor and dyskinesia.

Despite initial excellent response to DBS, progressively his tremor became refractory to stimulation adjustments, requiring large stimulation currents and two-hourly concomitant oral levodopa. Consequently, he developed disabling stimulation side-effects including mixed hypokinetic–spastic speech, borderline limbic changes and gait impairment. He was wheelchair-bound with a baseline Movement Disorder Society (MDS) Unified Parkinson’s Disease Rating Scale (UPDRS) III total score of 54.

Results: Foslevodopa/foscarbidopa was commenced with gradual titration to 0.27 mL/hr during the day and 0.25 mL for 7-8 hrs overnight. His UPDRS III score reduced to 39 at 4-weeks. No DBS stimulation changes were made during the 4-week observation period.

Using the MDS Non-Motor Symptoms Questionnaire (NMS-Q) Non-Motor Fluctuations Sub-Questionnaire, OFF symptoms reduced from 11-25% of the waking day, to ≤ 10% at 4-weeks.

Despite remaining wheelchair-bound, his quality of life (QoL) significantly improved as shown by decreased MDS NMS-Q total scores (baseline: 83 vs. 4-weeks: 31), and Parkinson’s Disease Questionnaire (PDQ-39) summary index (54 vs. 34).

Conclusion: In patients with advanced PD with optimally programmed DBS, yet persistent disabling motor fluctuations, continuous SC foslevodopa/foscarbidopa offers additional clinical and functional benefits to improve QoL.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/a-case-report-optimising-motor-and-non-motor-control-in-advanced-parkinsons-disease-the-role-of-foslevodopa-foscarbidopa-after-deep-brain-stimulation/