Objective: Staging of advanced treatments for Parkinson’s disease such as levodopa–carbidopa intestinal gel infusion (LCIG) and Deep brain stimulation (DBS)

Background: Device-aided therapies for Parkinson’s disease are widely used nowadays. They all aim at treating complications of oral dopaminergic medications. LCIG works well for motor fluctuations and troublesome dyskinesia overall; in Some cases, though, it may not provide sustained benefit for dyskinesia. DBS is an effective treatment for both motor fluctuations and dyskinesia. In a recent report (1) a PD patient underwent bilateral subthalamic nucleus (STN) DBS after initially being treated with LCIG.

Method: We describe a patient previously reported for being treated with LCIG for 6 years including during the course of pregnancy and delivery.

Results: A 45 year-old professional singer was diagnosed with PD (PIGD type) at the age of 29 years. Levodopa therapy was initiated at the age of 32 and led to dramatic improvement, but this was shortly followed by the appearance of dyskinesia, severe motor fluctuations and painful dystonia. She refused deep brain stimulation because of the risk of dysphonia. LCIG monotherapy was initiated at the age of 37, and resulted in improvement of motor fluctuations, gait and dyskinesia. While treated with LCIG she became pregnant and delivered a healthy baby. In the following years her condition deteriorated and she could hardly ambulate by herself, she needed help in ADL activities and had a caregiver for 24 hours/day. Due to worsening of dyskinesia on the one hand and painful off dystonia in her mouth and limbs the patient decided to discontinue LCIG therapy (1310 mg levodopa/day) and to initiate brain stimulation instead. In 6.2018 the patient underwent BIL GPI DBS (VERSICE PC) insertion. There were no operative or post- operative complications. After activating the DBS electrodes the patient experienced reduction both in the severity of off state, and in frequency and severity of dyskinesia. UPDRS III OFF pre DBS score was 34/103 and post DBS was 19/103. The patient could ambulate independently and was independent in ADL functions.

Conclusion: There is a growing need to develop new clinical algorithms for patients receiving advanced treatments in Parkinson’s disease.

References: Nathoo, Nabeela & Sankar, Tejas & Suchowersky, Oksana & Ba, Fang. (2018). Deep Brain Stimulation as a Rescue When Duodenal Levodopa Infusion Fails. Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques. 46. 1-2. 10.1017/cjn.2018.366.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/deep-brain-stimulation-as-second-line-advanced-treatment-for-pd-after-lcig/