The timing of continuous dopaminergic stimulation (CDS) therapy is an important consideration in achieving the most favourable motor outcomes. According to the official product information in Germany, levodopa/carbidopa intestinal gel (LCIG) infusion should be used for the ‘treatment of advanced, levodopa-responsive Parkinson’s disease with severe motor fluctuations AND hyper-/dyskinesia when available antiparkinsonian treatment is not satisfying anymore’.1 In Germany, younger patients without cognitive impairments are more likely to receive deep brain stimulation (DBS), while older patients with cognitive impairments are more likely to receive LCIG infusion therapy. In addition, there is a tendency in Germany for DBS to be performed when there is only ‘wearing off’ in patients, while LCIG infusion treatment is not initiated before there are more severe motor fluctuations including hyperkinesia. An interesting question is whether this approach to use LCIG treatment later in the course of the disease compared with DBS is optimal. Two patient cases are presented here to illustrate the effects of starting LCIG infusion at different stages of Parkinson’s disease (PD), and the effects of daytime-only LCIG infusion on overnight motor fluctuations.
Baseline Motor Performance
Two patient cases are presented and these are referred to as ‘Patient 1’ and ‘Patient 2’. Patient 1 is a man in his early 60s who experienced severe motor fluctuations. Sometimes he only had good motor ‘on’ for about 20 % of the day and was either ‘off’ or ‘on with severe dyskinesia’ for the remainder of the day. He sometimes shifted from ‘on’ with severe dyskinesia directly to the ‘off’ phase, and had very difficult nights with severe ‘off’ phases (see Table 1A). Patient 1 had depression, cognitive impairment and slight hallucinations, and was taking the following medications when he first presented at ourdepartment: levodopa 200 mg every three hours (six times daily), entacapone 200 mg every three hours (six times daily), amantadine 200 mg twice daily, cabergoline 4 mg once daily and levodopa at request (up to 600 mg a day). Most of the levodopa at request was taken at night to treat severe night-time ‘off’ phases. He also took mirtazapine 15 mg in the evening and escitalopram 10 mg in the morning for his depression, and quetiapine 25 mg in the evening for his hallucinations.
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