Objective: To explore the practical benefits and challenges of adding duodenal levodopa-carbidopa intestinal gel infusion (LCIG) to subthalamic nucleus deep brain stimulation (STN DBS) in patients with advanced Parkinson’s disease (PD)

Background: DBS, LCIG infusion and apomorphine subcutaneous infusion are treatment options for advanced Parkinson’s disease, but, there have been few reports on the combination use of these advanced therapies.1

Methods: Case reports on 2 patients

Results: Patient A, a 72 year-old male had onset at age 43, a 29-year history of PD. He developed motor fluctuation at age 57, and had STN DBS at age 65 when levodopa equivalent dose (LED) was 1299mg/d. Post-operatively, he managed the lowest LED of 375mg/d. He developed peak-dose and diphasic dyskinesia/ dystonia, freezing of gait and dysarthrophonia. With LED up to 1082mg/day by age 72, he developed mood elevation. DBS parameters adjustment including interleaving, low-frequency stimulation, and concomitant nigral stimulation did not improve his symptoms. LCIG infusion was added. Attempt was made to reduce his DBS stimulation against up-titration of his LCIG infusion to improve his speech, but caused intolerable hypotension. He developed diffuse thickening of the proximal jejunum, but his dyskinesia, behaviour and gait remained improved at 6 months follow-up. He remained on LED of 848mg/d. Patient B is a 76 year-old female with onset at age 53, a 23-year history of PD with prominent anxiety. She received STN DBS at age 71 because of motor fluctuation, dyskinesia, punding and obsessive behaviours, when her LED reached 1600mg/d. Post-operatively, she achieved her lowest LED at 925mg/d. Reduction in her LED caused “freezing episodes” and worsening anxiety, with dysarthrophonia. DBS readjustment with lower contacts worsened leg dyskinesia. Trials on interleaving configurations, concomitant nigral stimulation did not help. Her LED escalated over 4 years to 1796mg/d. LCIG infusion was instituted for uncontrollable dyskinesia, arriving at the LED of 2278mg/d. Attempt was made to reduce her DBS stimulation, but this worsened symptoms. The LED was not able to be reduced at 9 months follow-up. Her dyskinesia remained improved, though benign compulsive behaviours and gait difficulty persist.

Conclusions: LCIG infusion improved the motor-fluctuation, dyskinesia +/- axial symptoms of the 2 patients with advanced Parkinson’s disease treated with STN DBS, but did not replace the therapeutic role of the STN DBS, nor significantly reduce the LED.

References: 1. Regidor I, Benita V, Del Álamo de Pedro M, Ley L, Martinez Castrillo JC. Duodenal Levodopa Infusion for Long-Term Deep Brain Stimulation-Refractory Symptoms in Advanced Parkinson Disease. Clin Neuropharmacol. 2017.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/the-interface-of-advanced-therapies-as-parkinsons-disease-progresses-case-reports/