Parkinsons disease Gel Infusion protocol
Levodopa-carbidopa intestinal gel (LCIG) is used for Parkinson's disease to reduce motor fluctuations. It's delivered via a tube with a battery-powered pump. Vitamin B12 levels should be monitored, and patients may need additional oral levodopa at night if "wearing off" occurs. Precautions include potential adverse events and tube maintenance.
2024-01-07 01:41:37 - Editor
Indications for LCIG:
Levodopa- carbidopa intestinal gel (LCIG) is indicated for patients with Parkinson disease to reduce motor fluctuations and to decrease "off" effect. Also, for patients who are too frail to undergo DBS.
LCIG Delivery System:
LCIG comes in the form of a cassette containing levodopa/carbidopa suspension. It is delivered as a continuous infusion through a percutaneous gastrojejunostomy (PEG) tube by battery powered pump. The pump is put in a small bag and carried at the neck or the waist. (1, 2)
LCIG Protocol:
Baseline assessment of vitamin B 12, homocysteine and methylmalonic acid levels should be checked, with a subsequent vitamin B12 if needed to reduce the risk of neuropathy associated with it. Percutaneous gastrojejunostomy tube placement. An initial clinic visit is needed to explain the procedure in details, discuss side effects and ensure that patients are in “off” effect. Thereafter, LCIG infusion is initiated, replacing the total daily oral levodopa dose. LCIG is given in daytime as a morning bolus dose of levodopa followed by a continuous maintenance dose for 16 hours. Extra bolus doses can be used as needed to manage additional motor symptoms. Many patients find adequate control of symptoms with the daytime approach only. However, if they experience "wearing off" at night, they may benefit from a bedtime dose of oral levodopa. (3)
Precautions and Adverse Events:
Few adverse events may be related to the procedure including abdominal pain, skin infection, peritonitis, gastric reflux and aspiration. Also, LCIG requires daily flushing of the tube at the end of its administration as sudden cessation of the effect of levodopa may occur if the J- tube extension is displaced into the stomach. Finally, peripheral polyneuropathy may be related to vitamin B12 deficiency. (3, 4, 5)
References
1- Wirdefeldt K, Odin P, Nyholm D. Levodopa-Carbidopa Intestinal Gel in Patients with Parkinson's Disease: A Systematic Review. CNS Drugs 2016; 30:381.
2-Olanow CW, Kieburtz K, Odin P, et al. Continuous intrajejunal infusion of levodopa-carbidopa intestinal gel for patients with advanced Parkinson's disease: a randomised, controlled, double-blind, double-dummy study. Lancet Neurol 2014; 13:141.
3-Lang AE, Rodriguez RL, Boyd JT, et al. Integrated safety of levodopa-carbidopa intestinal gel from prospective clinical trials. Mov Disord 2016; 31:538.
4-Slevin JT, Fernandez HH, Zadikoff C, et al. Long-term safety and maintenance of efficacy of levodopa-carbidopa intestinal gel: an open-label extension of the double-blind pivotal study in advanced Parkinson's disease patients. J Parkinsons Dis 2015; 5:165.
5- Merola A, Romagnolo A, Zibetti M, et al. Peripheral neuropathy associated with levodopa-carbidopa intestinal infusion: a long-term prospective assessment. Eur J Neurol 2016; 23:501.