Objective: Report cases of biphasic dyskinesia in patients with advanced Parkinson’s disease.

Background: Diphasic dyskinesia (DD) is a complex pattern of levodopa (LD) induced diskynesia in patients with Parkinson´s disease (PD). It commonly cuases ballistic, kicking or bycicling leg movememts and frequently are associated mental distress and autonomic manifestations. With DD, the involuntary movements herald the onset and mark the end of the “on” period but continuous dopaminergic stimulation (CDS) may induce a “phasic” presentation pattern.

Method: We report 5 patients (2 male and 3 female; age: 55-75 years) with advanced Parkinson’s disease (from 8 to 12 years of evolution, stage III / V of Hoehn and Yahr).  With habitual therapeutic scheme the patients presented fluctuations, chorea “on” and severe frezzing, even during the “on” state in 3 of them, then, was indicated enterally administered levodopa / carbidopa gel treatment.

Results: In all patients “continuous” dopaminergic stimulation dramatically ameliorate “on- off” fluctuations and choreic “on” dyskinesias during same years. After chronic treatment with duodopa (more than 5 years; duodopa dose: morning dose: range 9-14.9 ml;  continuous dose: 3,5- 4 ml/hr; extra-dose of 1 -3 ml ) patients began with very severe involuntary movements in lower extremities in the afternoom. The  increase  infusion dose caused Chorea widespread and with the decrease in the dose worsened the frezzing and the parkinsonism and 2 patients developed off-dystonia. Subcutaneous apomorphine bolus improved the RAMs in two patients. In one patient was necessary suspending the infusion from 18 hours, for controlling dyskinesias.  2 patient improved with different duodopa-doses in the morning and in the afternoon.

Conclusion: Several drugs and delivery systems are now available for CDS, in order to stabilize the motor state in severe parkinsonism complicated by fluctuations and dyskinesias. RAMs and complex patterns of dyskinesias became a major troublesome complication in a proportion of cases. Diurnal variations of the pharmacodynamic striatal response are suggested explanation for this clinical observation.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/complex-patterns-of-dyskinesias-in-patients-chronically-treated-with-enterally-administered-levodopa-carbidopa-gel/