Objective: Include inhaled levodopa as a therapeutic option in those patients who, due to post-surgical problems, cannot use oral treatments.

Background: The development of motor fluctuations in Parkinson’s Disease (PD) with OFF, delayed ON and suboptimal ON episodes may require rescue therapies such as apomorphine or levodopa with different routes of administration.

Method: We describe a case of a 73-year-old patient with advanced Parkinson’s Disease and Hoehn and Yahr (HyY) III who, due to post-surgery digestive complications, was treated with inhaled levodopa. A literature review will also be carried out on the topic.

Results: The patient had advanced PD of at least 9 years of evolution, HyY III, MDS-UPDRS part III of 19 points. Due to severe motor fluctuations and severe dysphagia episodes, it was decided to start levodopa/carbidopa intestinal gel infusion as advanced therapy. His treatment at that time was oral levodopa divided into 6 doses, safinamide, rivastigmine and, for delayed ON in the morning and for unpredictable OFF, inhaled levodopa had been prescribed. He had presented intolerance to opicapone, rasagiline and dopamine agonists, the latter with impulse control disorder and hallucinations at low doses.

After gastrostomy, the patient had acute pain refractory to analgesia without signs of peritonism. An abdominal CT scan was requested to rule out complications such as perforation and confirm the correct placement of the probe. It was concluded that the patient had pneumoperitoneum and paralytic ileus as complications. For this reason, bowel rest, intravenous fluids and antibiotic therapy were started.

To avoid previous dopaminergic agonists related adverse events and because of mild confusional syndrome due to patient’s hospitalization, we prescribed five inhalations of levodopa per day to bypass enteral administration. Furthermore, in the afternoon the appearance of non-motor OFF referred to as nervousness and other than abdominal pain was identified, which also responded to therapy. After two weeks, oral levodopa was added with correct tolerance and the patient progressed favorably towards resolution of the condition, restarting the levodopa infusion with a good response (UPDRS III 10 points).

Conclusion: – Inhaled levodopa could be of choice in patients without tolerance to oral/enteral or transdermal treatments.

– Future studies should provide more real-life data on this utility beyond the objective of clinical trials.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/if-oral-levodopa-is-not-possible-keep-calm-and-breathe-deeply/