Objective: To report our experience with the use of levodopa-carbidopa intestinal gel (LCIG) infusion therapy for the treatment of four patients with idiopathic Parkinson’s disease (PD) associated with severe refractory tremors that are not responding to oral medications.
Background: Refractory tremor-predominant PD is characterized by prominent tremors of one or multiple limbs with a lack of significant bradykinesia and rigidity that is not responding to different classes of oral medications, including dopaminergic drugs, anticholinergics, amantadine, and benzodiazepines. The refractory tremor of these patients usually causes a significant impact on their quality of life. Neurosurgical interventions such as deep brain stimulation, thalamotomy, and thermocoagulation are established options with proven efficacy for disabling refractory tremors of PD (1). However, there is a paucity of data in the literature regarding the use of LCIG infusion for the treatment of the disabling refractory tremors of PD as an alternative mode of therapy.
Method: We report four patients with tremor-predominant PD; their mean age was 68 years, and the patient’s clinical features are shown in [table 1]. Initially, they showed a satisfactory response with oral dopaminergic medications and had reasonable tremor control; however, as the disease progressed, there was a decline in their clinical response despite receiving the maximum tolerated dose of oral medications. All four patients developed refractory debilitating tremors that caused significant disability. Three patients were poor candidates for neurosurgical interventions, and one preferred a less invasive procedure. An assessment of fitness for LCIG was done according to standard hospital protocol, and a PEG-J tube was inserted, LCIG infusion started, and the clinical response was measured pre and post-LCIG.
Results: Extended follow-up revealed excellent tremor control clinically that was measured by the Unified Parkinson Disease Rating Scale (UPDRS)-III, pre and post-LCIG. Infusion parameters were adjusted according to clinical response.
Conclusion: LCIG infusion therapy could be considered a promising alternative treatment for refractory tremor-predominant PD in patients who are poor surgical candidates or refusing neurosurgical interventions. Large-controlled studies are needed to fill the gaps in knowledge and benefit of this infusion therapy.
References: 1. Marjama-Lyons, J., & Koller, W. (2000). Tremor-predominant Parkinson’s disease. Approaches to treatment. Drugs & aging, 16(4), 273–278. https://doi.org/10.2165/00002512-200016040-00003
To cite this abstract in AMA style:M. Abu Al-Melh, N. Abdelall, T. Al-Otaibi. Levodopa-carbidopa intestinal gel for managing severe refractory tremors of idiopathic Parkinson’s disease: Case Series [abstract]. Mov Disord. 2023; 38 (suppl 1). https://www.mdsabstracts.org/abstract/levodopa-carbidopa-intestinal-gel-for-managing-severe-refractory-tremors-of-idiopathic-parkinsons-disease-case-series/. Accessed September 21, 2023.
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MDS Abstracts - https://www.mdsabstracts.org/abstract/levodopa-carbidopa-intestinal-gel-for-managing-severe-refractory-tremors-of-idiopathic-parkinsons-disease-case-series/