Treatment options in advanced Parkinson’s disease (PD) include subcutaneous apomorphine, pallidal or subthalamic nucleus Deep Brain Stimulation (DBS), or levodopa/carbidopa intestinal gel (LCIG/Duodopa). In this study, we describe the outcome of 12 PD patients with PD related complications started on LCIG, with respect to their quality of life measured by a disease specific validated scale—the PDQ39, together with diaries recording time spent “On,” “Off,” “Dyskinetic,” or “Asleep.” At the time of latest follow up, improvements were observed in both the PDQ39 Summary index as well as diary reports of PD symptom control following introduction of LCIG, supporting its use in well selected patients. The use of a trial period of LCIG via naso-jejunal administration allows objective evaluation of improvement in PD symptom control in advance of the placement of the more invasive percutaneous jejunostomy procedure. The decision to embark on LCIG, apomorphine or DBS should be supported by input from centres with experience of all 3 approaches. Since LCIG is an expensive option, development of the most appropriate future commissioning of this therapy in the absence of Class 1 evidence requires careful scrutiny of the outcomes of its use in a broad range of published series. 1. Introduction One of the key outcomes for the UK National Health Service Outcomes Framework 2012/2013 is “Enhancing the quality of life for people with long term conditions.” Neurodegenerative diseases including Parkinson’s disease (PD) represent a major target area for outcome improvement. While the majority of patients with Parkinson’s disease respond well to conventional oral medication, some patients (particularly those with young onset PD) survive for many decades with the illness and, in the later or “advanced” stages, experience severe disabling complications emerging from the combination of advancing degeneration and chronic medication use. These complications consist of severe adventitious involuntary movements often referred to as L-dopa-induced dyskinesias, and unpredictable “On/Off” fluctuations, necessitating the use of other strategies to maintain acceptable quality of life. Oral and transdermal anti-Parkinsonian therapy fails to provide sufficient relief from the symptoms of advanced PD in a significant proportion of patients, in whom consideration should be given regarding the use of subcutaneous apomorphine, subthalamic or pallidal Deep Brain stimulation (DBS), or levodopa/carbidopa intestinal gel (LCIG/Duodopa). Patients reaching the advanced stages of PD while still
References
[1]
J. I. Sage, S. Trooskin, P. K. Sonsalla, and R. E. Heikkila, “Experience with continuous enteral levodopa infusions in the treatment of 9 patients with advanced Parkinson's disease,” Neurology, vol. 39, supplement 12, no. 11, pp. 60–63, 1989.
[2]
M. C. Kurth, J. W. Tetrud, C. M. Tanner et al., “Double-blind, placebo-controlled, crossover study of duodenal infusion of levodopa/carbidopa in Parkinson's disease patients with “on-off” fluctuations,” Neurology, vol. 43, no. 9, pp. 1698–1703, 1993.
[3]
D. Nyholm, H. Askmark, C. Gomes-Trolin et al., “Optimizing levodopa pharmacokinetics: intestinal infusion versus oral sustained-release tablets,” Clinical Neuropharmacology, vol. 26, no. 3, pp. 156–163, 2003.
[4]
D. Nyholm, A. I. Nilsson Remahl, N. Dizdar et al., “Duodenal levodopa infusion monotherapy vs oral polypharmacy in advanced Parkinson disease,” Neurology, vol. 64, no. 2, pp. 216–223, 2005.
[5]
C. W. Olanow, A. Antonini, K. Kieburtz, H. H. Fernandez, A. J. Espay, D. Standaert, et al., “Randomised, double-blind, double-dummy study of continuous infusion of levodopa-carbidopa intestinal gel in patients with advanced Parkinson's disease: efficacy and safety,” Movement Disorders, vol. 27, Supplement 1, p. 411, 2012.
[6]
D. Nilsson, D. Nyholm, and S. M. Aquilonius, “Duodenal levodopa infusion in Parkinson's disease—long-term experience,” Acta Neurologica Scandinavica, vol. 104, no. 6, pp. 343–348, 2001.
[7]
A. Antonini, I. U. Isaias, M. Canesi et al., “Duodenal levodopa infusion for advanced Parkinson's disease: 12-Month treatment outcome,” Movement Disorders, vol. 22, no. 8, pp. 1145–1149, 2007.
[8]
A. Antonini, F. Mancini, M. Canesi et al., “Duodenal levodopa infusion improves quality of life in advanced Parkinson's disease,” Neurodegenerative Diseases, vol. 5, no. 3-4, pp. 244–246, 2008.
[9]
K. Eggert, C. Schrader, M. Hahn et al., “Continuous jejunal levodopa infusion in patients with advanced Parkinson disease: practical aspects and outcome of motor and non-motor complications,” Clinical Neuropharmacology, vol. 31, no. 3, pp. 151–166, 2008.
[10]
H. Honig, A. Antonini, P. Martinez-Martin et al., “Intrajejunal levodopa infusion in Parkinson's disease: a pilot multicenter study of effects on nonmotor symptoms and quality of life,” Movement Disorders, vol. 24, no. 10, pp. 1468–1474, 2009.
[11]
P. P. Urban, I. Wellach, S. Faiss et al., “Subacute axonal neuropathy in Parkinson's disease with cobalamin and vitamin B6 deficiency under duodopa therapy,” Movement Disorders, vol. 25, no. 11, pp. 1748–1752, 2010.
[12]
W. R. Gibb and A. J. Lees, “The relevance of the Lewy body to the pathogenesis of idiopathic Parkinson's disease,” Journal of Neurology Neurosurgery and Psychiatry, vol. 51, no. 6, pp. 745–752, 1988.
[13]
P. Reddy, P. Martinez-Martin, A. Rizos et al., “Intrajejunal levodopa versus conventional therapy in Parkinson disease: motor and nonmotor effects,” Clinical Neuropharmacology, vol. 35, no. 5, pp. 205–207, 2012.
[14]
H. Honig, A. Antonini, P. Martinez-Martin et al., “Intrajejunal levodopa infusion in Parkinson's disease: a pilot multicenter study of effects on nonmotor symptoms and quality of life,” Movement Disorders, vol. 24, no. 10, pp. 1468–1474, 2009.
[15]
D. Devos, Y. Agid, A. Al Khedr et al., et al., “Patient profile, indications, efficacy and safety of duodenal levodopa infusion in advanced Parkinson's disease,” Movement Disorders, vol. 24, no. 7, pp. 993–1000, 2009.
[16]
J. Lowin, A. Bergman, K. R. Chaudhuri, L. J. Findley, C. Roeder, M. Schifflers, et al., “A cost effectiveness analysis of levodopa/carbidopa intestinal gel compared to standard care in late stage Parkinson's disease in the UK,” Journal of Medical Economics, vol. 14, no. 5, pp. 584–593, 2011.
