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Vekhande C, Hamed M, Tremain G, Mah J, Shetty A, Lazarescu A, Suchowersky O. Levodopa-Carbidopa Intestinal Gel for Parkinson's Disease over 11 years: One Center's "Real-World" Experience. Can J Neurol Sci 2024; 51:379-386. [PMID: 37462070 DOI: 10.1017/cjn.2023.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND Levodopa-carbidopa intestinal gel (LCIG) therapy has been shown to be a safe and effective treatment for advanced Parkinson's disease (PD). Limited data are available regarding long-term benefits and complications in Canada. Objective of the study was to review long-term experience and clinical outcomes in PD patients with LCIG therapy over 11 years in a multidisciplinary University clinic setting. METHODS Chart review was done on PD patients with LCIG from 2011 to 2022. Data collected: dosing, UPDRS-III motor scores, OFF times, hours with dyskinesias, MoCA, complications, discontinuation reasons, and nursing time requirements. RESULTS Thirty-three patients received LCIG therapy with a mean follow-up of 3.25±2.09 years. UPDRS-III scores showed reduction of 15% from baseline (mean 35.9) up to 4 years (mean 30.4). Daily OFF time improved from baseline (mean 7.1 ± 3.13 hours) up to 5 years (mean 3.3 ± 2.31 hours; -53.5%; p < 0.048), and dyskinesias remained stable. Nursing time averaged 22 hours per patient per year after PEG-J insertion and titration. Most common complications were PEG-J tube dislodgement and stoma site infection (0-3zero to three events/patient/year). Serious side effects were seen in four (12%) patients resulting in hospitalization and/or death. Nine patients (27.2%) discontinued the treatment due to lack of improved efficacy over oral therapy or development of dementia and 10 (30%) died of causes unrelated to LCIG infusion. CONCLUSION Patients on LCIG showed improved motor function over 5-year follow-up. Serious complications were uncommon. Dedicated nursing time is required by LCIG-trained nurses in a multidisciplinary setting for optimum management.
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Affiliation(s)
- Chetan Vekhande
- Department of Medicine (Neurology), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Moath Hamed
- Department of Neuroscience, NYP Brooklyn, Methodist Hospital, New York, NY, USA
| | - Genise Tremain
- Movement Disorders Program, Kaye Edmonton Clinic, Alberta Heath Services, Edmonton, AB, Canada
| | - Jennifer Mah
- Movement Disorders Program, Kaye Edmonton Clinic, Alberta Heath Services, Edmonton, AB, Canada
| | - Aakash Shetty
- Department of Medicine (Neurology), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Adriana Lazarescu
- Department of Medicine (Gastroenterology), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Oksana Suchowersky
- Department of Medicine (Neurology), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Movement Disorders Program, Kaye Edmonton Clinic, Alberta Heath Services, Edmonton, AB, Canada
- Department of Pediatrics, Psychiatry and Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Auffret M, Weiss D, Stocchi F, Vérin M, Jost WH. Access to device-aided therapies in advanced Parkinson's disease: navigating clinician biases, patient preference, and prognostic uncertainty. J Neural Transm (Vienna) 2023; 130:1411-1432. [PMID: 37436446 PMCID: PMC10645670 DOI: 10.1007/s00702-023-02668-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Abstract
Device-aided therapies (DAT), which include deep brain stimulation and pump-based continuous dopaminergic stimulation with either levodopa or apomorphine, are among the major advances in the clinical management of Parkinson's disease (PD). Although DAT are being increasingly offered earlier in the disease course, their classical indication remains advanced PD. Theoretically, every patient should be offered transition to DAT when faced with refractory motor and nonmotor fluctuations and functional decline. Worldwide clinical reality is far from these ideal, and, therefore, question the "real-world" equal opportunity of access to DAT for PD patients with advanced PD-even within a single health care system. Differences in access to care, referral pattern (timing and frequency), as well as physician biases (unconscious/implicit or conscious/explicit bias), and patients' preferences or health-seeking behaviour are to be considered. Compared to DBS, little information is available concerning infusion therapies, as well as neurologists' and patients' attitudes towards them. This viewpoint aims to be thought-provoking and to assist clinicians in moving through the process of DAT selection, by including in their decision algorithm their own biases, patient perspective, ethical concerns as well as the current unknowns surrounding PD prognosis and DAT-related long-term side effects for a given patient.
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Affiliation(s)
- Manon Auffret
- France Développement Electronique (FDE), Monswiller, France.
- Institut des Neurosciences Cliniques de Rennes (INCR), Rennes, France.
- Behavior and Basal Ganglia Research Unit, CIC-IT, CIC1414, Pontchaillou University Hospital and University of Rennes, Rennes, France.
| | - Daniel Weiss
- Centre for Neurology, Department for Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Fabrizio Stocchi
- University San Raffaele Roma and Institute of Research and Medical Care IRCCS San Raffaele Roma, Rome, Italy
| | - Marc Vérin
- Institut des Neurosciences Cliniques de Rennes (INCR), Rennes, France
- Behavior and Basal Ganglia Research Unit, CIC-IT, CIC1414, Pontchaillou University Hospital and University of Rennes, Rennes, France
- Neurology Department, Pontchaillou University Hospital, rue Henri Le Guilloux, 35000, Rennes, France
| | - Wolfgang H Jost
- Parkinson-Klinik Ortenau, Kreuzbergstr. 12-16, 77709, Wolfach, Germany
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Nomoto Y, Furihata M, Hagiwara H, Ishino H, Yano S, Okawa H, Nakatsu Y, Noda K, Nishi S, Ogiwara S, Kitamura T, Osada T. Transgastric Jejunostomy (PEG-J) for Continuous Infusion of Levodopa-Carbidopa Intestinal Gel: An Approach for Parkinson's Disease Treatment. Med Sci Monit 2023; 29:e941285. [PMID: 37571821 PMCID: PMC10429380 DOI: 10.12659/msm.941285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Parkinson's disease (PD) is a neurodegenerative disorder that often requires long-term management of motor symptoms. Continuous infusion of levodopa-carbidopa intestinal gel (LCIG) has shown promising results in alleviating motor fluctuations and improving quality of life. This study aimed to evaluate the efficacy and safety of transgastric jejunostomy (PEG-J) as a delivery method for LCIG in a cohort of 43 PD patients. MATERIAL AND METHODS Forty-three PD patients who were candidates for LCIG therapy underwent transgastric jejunostomy to facilitate continuous infusion of LCIG. The primary outcomes assessed were motor symptom improvement, reduction in motor fluctuations, and medication-related adverse events. Secondary outcomes included changes in quality of life, dyskinesia severity, and healthcare resource utilization. RESULTS The results of this study demonstrated significant improvements in motor symptoms, reduction in motor fluctuations, and enhanced quality of life following PEG-J for LCIG infusion. The treatment was generally well-tolerated, with a low incidence of procedure-related complications. Notably, the use of PEG-J allowed for precise and continuous delivery of LCIG, minimizing variations in drug absorption and ensuring consistent therapeutic levels. CONCLUSIONS Transgastric jejunostomy (PEG-J) offers an effective approach for the continuous infusion of LCIG in Parkinson's disease treatment. This method provides a stable and reliable delivery system, leading to improved symptom control and enhanced quality of life for PD patients.
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Bourgeois A, Gkolfakis P, Fry L, Arvanitakis M. Jejunal access for enteral nutrition: A practical guide for percutaneous endoscopic gastrostomy with jejunal extension and direct percutaneous endoscopic jejunostomy. Best Pract Res Clin Gastroenterol 2023; 64-65:101849. [PMID: 37652649 DOI: 10.1016/j.bpg.2023.101849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/02/2023] [Indexed: 09/02/2023]
Abstract
For patients requiring long-term (>4 weeks) jejunal nutrition, jejunal medication delivery, or decompression, a percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) or a direct percutaneous endoscopic jejunostomy (DPEJ) may be indicated. PEG-J is the preferred option if a PEG tube is already in place or if simultaneous gastric decompression and jejunal nutrition are needed. DPEJ is recommended for patients with altered anatomy due to foregut surgery, high risk of jejunal extension migration, and whenever PEG-J fails. Successful placement rates are lower for DPEJ but recent publications have reported improvements, partly due to the use of balloon-assisted enteroscopy. Both techniques are contraindicated in cases of active peritonitis, uncorrectable coagulopathy, and ongoing bowel ischaemia, and relative contraindications include, among other, peptic ulcer disease and haemodynamic or respiratory instability. In this narrative review, we present the most recent evidence on indications, contraindications, technical considerations, adverse events, and outcomes of PEG-J and DPEJ.
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Affiliation(s)
- Amélie Bourgeois
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Lucia Fry
- Internal Medicine, Gastroenterology and Geriatrics, Frankenwaldklinikum Kronach, Germany
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.
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Reardon J, Truax AE, Naranian T, Liu LWC. Enhancing Self-Management of Percutaneous Endoscopic Gastrostomy Tubes Through the Implementation of a Standardized Education and Assessment Pathway: A Quality Improvement Initiative. Gastroenterol Nurs 2023; 46:41-46. [PMID: 36706141 DOI: 10.1097/sga.0000000000000689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 07/01/2022] [Indexed: 01/28/2023] Open
Abstract
Intraduodenal infusion of levodopa-carbidopa intestinal gel by percutaneous endoscopic gastrostomy tube with jejunal extension is a treatment option to reduce motor and nonmotor complications in patients with advanced Parkinson's disease when oral therapy no longer provides sufficient benefit. Medication management is of central focus; however, there was no standardized patient education on stoma-site care and tube maintenance, leading to the development of stoma-site complications. As a quality improvement (QI) initiative, a standardized education and assessment pathway was developed and implemented in an urban academic outpatient clinic to enhance patient self-management and reduce stoma-site complications. A retrospective chart review was conducted to establish baseline incidence of cutaneous stoma-site complications. QI interventions were implemented using a rapid-cycle improvement model. Routine stoma assessments by a nurse who specializes in wound, ostomy, and continence care were implemented at set points, and patient education on PEG tube care and maintenance was reinforced at each session. Results demonstrated a significant reduction in moderate-to-severe tube and stoma-site-related complication. Implementation of a similar standardized education and assessment pathway in patients with percutaneous endoscopic gastrostomy tubes may lead to a decrease in stoma-site-related complications and overall better patient self-management.
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Affiliation(s)
- Joyce Reardon
- Joyce Reardon, MN, RN, CWOCN, WOCC(C), is a Clinical Nurse Specialist-Wound, Ostomy, Continence, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Alexis Truax, MClSc-WH, RN, WOCC(C), is a Clinical Nurse Specialist-Wound, Ostomy, Continence, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Taline Naranian, BScN, RN, is a Registered Nurse, Movement Disorders Clinic, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Louis W. C. Liu, PhD, MD, FRCP(C), is the Division Head of Gastroenterology and Hepatology, University Health Network and Sinai Health, Toronto, Ontario, Canada
| | - Alexis-Evelyn Truax
- Joyce Reardon, MN, RN, CWOCN, WOCC(C), is a Clinical Nurse Specialist-Wound, Ostomy, Continence, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Alexis Truax, MClSc-WH, RN, WOCC(C), is a Clinical Nurse Specialist-Wound, Ostomy, Continence, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Taline Naranian, BScN, RN, is a Registered Nurse, Movement Disorders Clinic, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Louis W. C. Liu, PhD, MD, FRCP(C), is the Division Head of Gastroenterology and Hepatology, University Health Network and Sinai Health, Toronto, Ontario, Canada
| | - Taline Naranian
- Joyce Reardon, MN, RN, CWOCN, WOCC(C), is a Clinical Nurse Specialist-Wound, Ostomy, Continence, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Alexis Truax, MClSc-WH, RN, WOCC(C), is a Clinical Nurse Specialist-Wound, Ostomy, Continence, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Taline Naranian, BScN, RN, is a Registered Nurse, Movement Disorders Clinic, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Louis W. C. Liu, PhD, MD, FRCP(C), is the Division Head of Gastroenterology and Hepatology, University Health Network and Sinai Health, Toronto, Ontario, Canada
| | - Louis W C Liu
- Joyce Reardon, MN, RN, CWOCN, WOCC(C), is a Clinical Nurse Specialist-Wound, Ostomy, Continence, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Alexis Truax, MClSc-WH, RN, WOCC(C), is a Clinical Nurse Specialist-Wound, Ostomy, Continence, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Taline Naranian, BScN, RN, is a Registered Nurse, Movement Disorders Clinic, Toronto Western Hospital-University Health Network, Toronto, Ontario, Canada
- Louis W. C. Liu, PhD, MD, FRCP(C), is the Division Head of Gastroenterology and Hepatology, University Health Network and Sinai Health, Toronto, Ontario, Canada
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Rota S, Urso D, van Wamelen DJ, Leta V, Boura I, Odin P, Espay AJ, Jenner P, Chaudhuri KR. Why do 'OFF' periods still occur during continuous drug delivery in Parkinson's disease? Transl Neurodegener 2022; 11:43. [PMID: 36229860 PMCID: PMC9558383 DOI: 10.1186/s40035-022-00317-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
Continuous drug delivery (CDD) is used in moderately advanced and late-stage Parkinson’s disease (PD) to control motor and non-motor fluctuations (‘OFF’ periods). Transdermal rotigotine is indicated for early fluctuations, while subcutaneous apomorphine infusion and levodopa-carbidopa intestinal gel are utilised in advanced PD. All three strategies are considered examples of continuous dopaminergic stimulation achieved through CDD. A central premise of the CDD is to achieve stable control of the parkinsonian motor and non-motor states and avoid emergence of ‘OFF’ periods. However, data suggest that despite their efficacy in reducing the number and duration of ‘OFF’ periods, these strategies still do not prevent ‘OFF’ periods in the middle to late stages of PD, thus contradicting the widely held concepts of continuous drug delivery and continuous dopaminergic stimulation. Why these emergent ‘OFF’ periods still occur is unknown. In this review, we analyse the potential reasons for their persistence. The contribution of drug- and device-related involvement, and the problems related to site-specific drug delivery are analysed. We propose that changes in dopaminergic and non-dopaminergic mechanisms in the basal ganglia might render these persistent ‘OFF’ periods unresponsive to dopaminergic therapy delivered via CDD.
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Affiliation(s)
- Silvia Rota
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK. .,Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK. .,Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Daniele Urso
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Centre for Neurodegenerative Diseases and the Aging Brain, Department of Clinical Research in Neurology, University of Bari 'Aldo Moro, "Pia Fondazione Cardinale G. Panico", 73039, Tricase, Italy
| | - Daniel J van Wamelen
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK.,Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Valentina Leta
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK
| | - Iro Boura
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,School of Medicine, University of Crete, Crete, Greece.,Department of Neurology, University Hospital of Heraklion, Crete, Greece
| | - Per Odin
- Division of Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Alberto J Espay
- University of Cincinnati Gardner Neuroscience Institute, Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Peter Jenner
- Institute of Pharmaceutical Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.
| | - K Ray Chaudhuri
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Parkinson's Foundation Centre of Excellence, King's College Hospital, London, UK
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Ivanov T, Perlot I, Stoca LR, Deleuze C, Rasmont C, Lemaitre J. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac118. [PMID: 35355578 PMCID: PMC8963146 DOI: 10.1093/jscr/rjac118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
We report a case of small bowel occlusion due to the formation of a bezoar around a knot at the distal end a gastro-jejunal catheter used for continuous levodopa/carbidopa intestinal gel (LCIG) in a patient with advanced Parkinson’s disease. The patient presented with a history of abdominal pain and vomiting starting 24 h before admission and frequent failure of his LCIG device for the past week. Small bowel occlusion along with a knot formation on the distal catheter was confirmed by contrast enhanced CT scan. After failure of endoscopic extraction, the patient was taken to theater. The presence of a knot and a bezoar was confirmed and extraction proceeded via transverse enterotomy without the need for bowel resection. Despite inhalation pneumonia and prolonged ileus, the patient recovered fully. LCIG treatment was reinstated a month later through new gastro-jejunal catheter. This case highlights a severe and surprising complication of LCIG treatment.
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Affiliation(s)
- Todor Ivanov
- Correspondence address: E-mail: ; Tel: 0032/472764283
| | - Ingrid Perlot
- CHU Ambroise Paré, Department of Gastro-Enterology, Mons, Belgique
| | | | | | - Celine Rasmont
- CHU Amboirse Paré, Department of Surgery, Mons, Belgique
| | - Jean Lemaitre
- CHU Amboirse Paré, Department of Surgery, Mons, Belgique
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