24-Hour Levodopa-Carbidopa Intestinal Gel: Clinical Experience and Practical Recommendations

Abstract

Infusion of levodopa-carbidopa intestinal gel (LCIG; also designated carbidopa-levodopa enteral suspension) for 16 hours is a standard treatment for patients with advanced Parkinson's disease, and clinical observations suggest that 24-hour LCIG infusion may further reduce symptoms. This review provides practical advice on the management of patients transitioning to 24-hour LCIG infusion. We review available clinical data for 24-hour infusion and discuss adjustments to dosing, recommendations for monitoring, and management of patient concerns, based on our clinical experience. Data from multiple studies suggest that LCIG may improve non-motor symptoms. Although few studies have examined 24-hour LCIG infusion, available data indicate that certain patients may benefit from around-the-clock treatment. Studies of 24-hour LCIG infusion are limited by small sample sizes and open-label study designs, which may hamper translation to clinical practice. In our experience, we have found that patients may benefit from 24-hour infusion when reductions in nocturnal symptoms and improvements to quality of sleep are needed. Levodopa-unresponsive freezing of gait or poorly controlled troublesome dyskinesias may also indicate a patient may benefit from 24-hour infusion. Dose adjustments, especially of the nocturnal rate, are typically necessary and, as with 16-hour infusion, patients should be monitored for autonomic dysfunction; overnight wearing off symptoms; weight changes; fluctuations in plasma levels of vitamins B 6 /B 12 , folate, and homocysteine; changes in sleep patterns; or worsening of hallucinations, delusions, and/or nightmares. Available data and our clinical experience suggest that 24-hour LCIG may be warranted among selected patients who have poorly controlled nocturnal fluctuations or early morning "off" symptoms.

Levodopa-Carbidopa Intestinal Gel may improve treatment-resistant freezing of gait in Parkinson’s disease

“…The search yielded 16 articles, of which we included 10. Thakkar et al [44] was excluded because it was a literature review on 24-hour LCIG compared to 16-hour LCIG without reportable data relevant to FOG. Vijiaratnam et al [45] was excluded because it examined patient outcomes following a modification to standard LCIG procedure, but did not evaluate the effectiveness of LCIG on FOG.…”

Current Knowledge on the Background, Pathophysiology and Treatment of Levodopa-Induced Dyskinesia—Literature Review

“…As mentioned in the clinical background section, one of the CDS methods is the use of levodopa-carbidopa intestinal gel (LCIG) [ 109 ]. In patients with advanced PD, the standard of care is a 16-hour long infusion of LCIG, whose superiority over oral L-DOPA in improving the life quality and motor functions in these patients has been repeatedly described in various populations of observational studies and clinical trials (phase three) [ 167 , 168 , 169 , 170 , 171 , 172 , 173 ]. It has been shown to reduce dyskinesia by more than 40% [ 168 ].…”

Comparative Effectiveness of Carbidopa–Levodopa Enteral Suspension and Deep Brain Stimulation on Parkinson’s Disease-Related Pill Burden Reduction in Advanced Parkinson’s Disease: A Retrospective Real-World Cohort Study

“…Furthermore, patients on CLES monotherapy achieved reduced “off”-time and increased “on”-time without troublesome dyskinesia [ 22 , 25 ]. While it was not possible to evaluate whether patients were receiving CLES for 16 h/day or 24 h/day from the MarketScan database, there is a possibility that patients receiving CLES for 24 h/day may have a greater reduction in pill burden [ 27 ]. Based upon previous studies and the findings of the current analysis, pill burden reduction may be considered an important treatment goal to optimize patient outcomes in advanced PD.…”