Objective: We report a case of a patient with advanced PD who began LCIG for refractory motor fluctuations while continuing longstanding STN-DBS.

Background: LCIG and DBS are device therapies with established efficacy for motor fluctuations in advanced PD. There is little data to guide decision-making for patients who develop refractory symptoms with one device in place.  A review of the literature reveals only 2 prior reported cases of combined LCIG and DBS.¹ Patients on DBS can require concomitant oral Levodopa and are therefore dependent on the motility and function of the GI tract. Consequently, dysautonomia and gastroparesis can lead to improper response to oral medication. We propose that there may be a rationale for adding LCIG to DBS for patients with GI symptoms impeding oral drug delivery.

Methods: The patient’s medical records were reviewed from 2008-2016. Data was extracted on UPDRS motor scores, subjective symptoms, DBS settings, and medications.

Results:

We present the case of a 61-year-old man treated with LCIG and DBS. His PD was diagnosed at 49.  6 years later, he developed refractory “offs” and underwent bilateral STN-DBS.  His symptoms were controlled for 4 years on STN-DBS and oral Levodopa. His UPDRS motor score improved from 31 to 12, daily Levodopa declined from 1700 to 1250 mg, and he no longer needed Mirapex and Apokyn. 

5 years later, he developed bothersome peak-dose dyskinesias and gastroparesis refractory to Domperidone and Tigan. Over the next 2 years, despite changes to DBS settings and medication, his symptoms progressed to persistent dyskinesias, biweekly falls, and deep “offs.” His UPDRS increased by 8-12 points. He required Neupro and developed ICD.

He began LCIG nearly 7 years after DBS.  His DBS was continued, though turned down, as he remained responsive with UPDRS uptrending though significantly below his pre-DBS baseline. Oral Levodopa was discontinued. His daily Levodopa on LCIG ranged from 1050-1500 mg.  He reported resolution of bothersome dyskinesias and reduction in falls to 2 in 6 months.  His UPDRS motor score declined by 6 points.  He no longer required Neupro and ICD resolved.

Conclusions: This is the first reported case from the U.S. of combined LCIG and DBS, and third overall. We are the first to describe a patient with DBS with added LCIG due to gastroparesis.¹ This case demonstrates that combined device therapy may be an option for patients whose symptoms have become refractory to one device.  LCIG may be an option for patients on DBS requiring Levodopa who develop worsening motor fluctuations in the setting of gastroparesis. The addition of LCIG to longstanding DBS is a logical sequence of therapies given that DBS can be performed in younger patients who are better neurosurgical candidates, with option to begin LCIG at a later date if needed. Further research is warranted on the safety, efficacy, and optimal usage of combined device therapies.

References: [1] Klostermann F et al. Jejunal levodopa infusion in long-term DBS patients with Parkinson’s Disease. Movement Disorders. 2011; 26: 2298-2299.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/combined-surgical-therapies-for-optimal-management-of-advanced-parkinsons-disease/