Parkinsons disease Diphasic Dyskinesia

Diphasic dyskinesia, characterized by two peaks of dyskinesia after levodopa doses, can be challenging to manage. Strategies include adjusting levodopa dosing, adding dopamine agonists, and considering infusion therapies or surgeries if other options fail.

Overview of Diphasic Dyskinesia:

Diphasic dyskinesia is an uncommon and often unrecognised type of dyskinesia. It peaks twice after each dose, first when the patient turns "on" and again when they begin to turn "off". In the second phase, dyskinesia; which is often large- amplitude movements involving the legs, manifest with either bradykinesia or tremor. (1)

Management Strategies:

The diphasic pattern is hard to manage and usually requires more frequent and low doses of levodopa to prevent "wearing off" effect prior to each dose. However, this strategy may lead to the risk of “peak- dose” dyskinesia. Then, the addition of a dopamine agonist may help and has to be considered. (2) If the above strategies are unhelpful, then continuous levodopa/ carbidopa intestinal gel infusion delivered through a percutaneous gastrojejunostomy (PEG) tube; with a strict monitor of infusion rates and bolus doses, subcutaneous apomorphine or device- assisted surgeries should be tried. (2, 3)

References

1- Fox SH, Lang AE. Levodopa-related motor complications--phenomenology. Mov Disord 2008; 23 Suppl 3:S509.

2- Odin P, Ray Chaudhuri K, Slevin JT, et al. Collective physician perspectives on non-oral medication approaches for the management of clinically relevant unresolved issues in Parkinson's disease: Consensus from an international survey and discussion program. Parkinsonism Relat Disord 2015; 21:1133.

3- Williams DR, Evans AH, Fung VSC, et al. Practical approaches to commencing device-assisted therapies for Parkinson disease in Australia. Intern Med J 2017; 47:1107.