Parkinsons disease Levodopa Induced Dyskinesia

Overview of Levodopa-Related Dyskinesia:

Levodopa related dyskinesia is an involuntary movement which is related to the use of levodopa. They include a variety of involuntary movements, such as, chorea, dystonia, and myoclonus. (1, 2)

Types of Dyskinesia:

1-Peak-dose dyskinesia appears as an "on" effect. It is usually choreiform in nature. (For more details, please refer to the heading “Parkinsons disease: Peak dose dyskinesia”)

2-Diphasic dyskinesia is a rare form of dyskinesia leading to two separate periods of involuntary movement after the dose of levodopa. (For more details, please refer to the heading “Parkinson disease: Diphasic Dyskinesia”)

3-Dystonia which is either “wearing off” or “peak dose”;

A-“Wearing off”- Dystonia; it involves mainly the limb; but may also involve the face or the trunk. It occurs in "off" periods, such as the morning before levodopa dose. It is characterised by muscle contractions causing abnormal and repetitive movements and dystonic postures.

Management of "Off" Dystonia:

For management of "Off" Dystonia; Controlled release levodopa (CR) at a starting dose of 50/200 mg orally twice a day is advised to be taken at the night or first thing in the morning. An alternative approach is by using rescue agents; such as; apomorphine at 1 mg (0.1 ml), subcutaneously and the patient has to be observed over 30 minutes. A second dose of 2mg could be tried if inadequate response. Please also refer to the heading “Parkinson disease: Wearing off Phenomena” for more details about “other rescue strategies” as their management is the same. (3) B-“Peak-dose” dystonia is managed in the same way as peak-dose dyskinesia. (Please refer to the heading “Parkinson disease: Peak dose dyskinesia”)

References

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

2-Quinn N. Drug treatment of Parkinson's disease. BMJ 1995; 310:575.

3- Trenkwalder C, Chaudhuri KR, García Ruiz PJ, et al. Expert Consensus Group report on the use of apomorphine in the treatment of Parkinson's disease--Clinical practice recommendations. Parkinsonism Relat Disord 2015; 21:1023.