Objective: [To describe a novel cause for unpredictable response to levodopa]

Background: A fluctuating response to levodopa is common in advanced Parkinson’s disease and can often be attributed to dosing regimen, interaction with food and delayed gastric emptying.  Failure to respond to levodopa is often an indication of a parkinsonism plus syndrome.

Methods: CASE: A 70 year-old man was referred because of failure to respond to levodopa and suspicion that he had some other form of parkinsonism.  The subject reported that even at single doses of 400 mg, levodopa was ineffective, a fact that had been confirmed by other neurologists’ post dose examinations.  However, the patient described that he would sometimes have a period of mobility and dyskinesia during the day with no relation to medication intake.

Results: A challenge with 400 mg of PO levodopa in the practical off state in the clinic found that he had a minimal improvement in his rigidity an hour and a half after intake and by 3 hours had not achieved an optimal response. A referral to GI for a trial with nasojejunal administration of levodopa found a huge paraesophageal hernia with almost the entire stomach in the chest.   Administration of carbidopa/levodopa gel (Duopa) by pump via the nasojejual tube gave the patient a full response to levodopa within 45 minutes each morning and he remained on most of the day.  As there was insufficient stomach in the abdomen to do endoscopic placement of the jejunal tube the patient had a jejunostomy by laproscopic surgery.  He now has a predictable response to the infusions of the levodopa/carbidopa gel by pump.

Conclusions: Structural abnormalities of the upper GI tact may complicate oral levodopa treatment.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/a-novel-cause-for-unpredictable-response-to-levodopa/