Can suitable candidates for levodopa/carbidopa intestinal gel therapy be identified using current evidence?

Abstract

Advanced Parkinson's disease (APD) is characterized by increased functional disability, caused by motor complications, the presence of axial symptoms, and emergent disease- and drug-related non-motor symptoms. One of the advanced therapies available is intrajejunal infusion of levodopa/carbidopa intestinal gel (LCIG); however, patient selection for this treatment is sometimes difficult, particularly because of overlapping indications with other alternatives.In recent years, strong evidence has supported the use of LCIG in treating motor fluctuations associated with APD, and several clinical studies provide emerging evidence for additional benefits of LCIG treatment in certain patients. This article provides an overview of the published literature on the benefits, limitations, and drawbacks of LCIG in relation to PD symptoms, the psychosocial impact of the disease, and the quality of life of patients, with the aim of determining candidates for whom treatment with LCIG would be beneficial. According to current evidence, patients with APD (defined as inability to achieve optimal control of the disease with conventional oral treatment), a relatively well-preserved cognitive-behavioral status, and good family/caregiver would count as suitable candidates for LCIG treatment. Contraindications in the opinion of the authors are severe dementia and active psychosis.

Intrajejunal vs oral levodopa-carbidopa therapy in Parkinson disease

“…[ 9 ] The result was that patients showed statistically significant ( P < .05) higher performances in activities of daily living, statistically significant ( P < .001) lower incidence and severity of motor fluctuations, as rating by UPDRS part IV, compared to their best oral therapy and the success rate for PEG-J placement was 100%. [ 9 ] Previous research found that continuous intrajejunal infusion of LCIG provide a significant clinical improvement and improves UPDRS, [ 10 – 13 ] a result similar to ours. However, device and procedural complications, while generally of mild severity, were present and were explained by the severity and progression of the disease.…”

“…However, device and procedural complications, while generally of mild severity, were present and were explained by the severity and progression of the disease. [ 10 – 13 ]…”

Long‐term effect of levodopa‐carbidopa intestinal gel on axial signs in Parkinson’s disease

“…Moreover, although some l ‐dopa unresponsive axial symptoms are not mandatory exclusion criteria for LCIG treatment initiation, clinicians should take into account that a milder axial response to l ‐dopa at baseline implies a worse outcome in terms of FOG and a lower independency in ADLs at long‐term FU. Patients’ selection for LCIG treatment can be challenging, and the identification of the “best candidate” or the “optimal timing” is still a matter of debate . No strong evidences actually support the indication of LCIG treatment starting at the beginning of the advanced phase or its possible disease‐modifying effect.…”

Levodopa-Induced Dyskinesias and Dyskinesias-Reduced-Self-Awareness in Parkinson’s Disease: A Neurocognitive Approach

“…On the other hand, LCIG does not seem to accelerate cognitive deterioration, and no significant differences in the long-term cognitive decline were reported in comparison with DBS or oral medical treatment [21]. Finally, amelioration of depression, anxiety, impulse control disorder, and psychosis has also been reported [20].…”

“…Nevertheless, the patient's cognitive status has to be carefully evaluated. In fact, due to the gastrostomy and device management, the presence of severe cognitive impairment could unbalance the risk/benefit profile toward lower efficacy and higher prevalence of complications and side effects [20]. For the same reason, the presence of a caregiver is strongly recommended in patients with mild to moderate cognitive impairment undergoing LCIG treatment.…”