Paolo Solla1, Alfonso Fasano2, Antonino Cannas3, Cesare Salvatore Mulas3, Maria Giovanna Marrosu3, Anthony E Lang2, Francesco Marrosu3. 1. Movement Disorders Center, Department of Neurology, Institute of Neurology, University of Cagliari, Cagliari, Italy. Electronic address: paosol29@yahoo.it. 2. The Edmond J. Safra Program in Parkinson's Disease, Movement Disorders Center, Toronto Western Hospital, Division of Neurology, University of Toronto, Canada. 3. Movement Disorders Center, Department of Neurology, Institute of Neurology, University of Cagliari, Cagliari, Italy.
Abstract
OBJECTIVES: Levodopa-carbidopa intestinal gel infusion (LCIG) is indicated in patients with advanced levodopa-responsive Parkinson's disease (PD) for the treatment of motor fluctuations and dyskinesias unsatisfactorily managed with conventional medication. The outcome of non-motor symptoms - particularly affective and behavioral ones - following LCIG initiation remains scarcely explored, especially with respect to the changes undergone by oral dopaminergic drugs. Here we describe 4 PD patients who developed dopamine agonist withdrawal syndrome (DAWS) symptoms correlated with rapid taper of these drugs after LCIG initiation. METHODS: We identified 4 cases developing apathy and depression after the rapid withdrawal of Dopamine agonists (DAs) consequent to LCIG introduction. The clinical data were obtained through detailed review of medical records. RESULTS: Within few days after DAs withdrawal, all 4 patients developed apathy, anhedonia and depression, despite the marked reduction of dyskinesias and the improvement of motor fluctuations after LCIG introduction. We unsuccessfully tried to manage these and other DAWS symptoms by increasing LCIG flow. Within 6 months, all patients spontaneously presented a slow but gradual improvement of DAWS symptoms, not requiring any further treatment strategy or LCIG discontinuation. CONCLUSIONS: To our knowledge, this is the first report describing the occurrence of DAWS symptoms in advanced PD patients after DAs withdrawal in LCIG and highlighting the difficulty of distinguishing postoperative effects from drug withdrawal symptoms. Therefore we wish to draw attention of clinicians to the risk of developing DAWS in advanced PD patients switched to LCIG monotherapy. In such cases, a rapid taper of DAs should be avoided.
OBJECTIVES:Levodopa-carbidopa intestinal gel infusion (LCIG) is indicated in patients with advanced levodopa-responsive Parkinson's disease (PD) for the treatment of motor fluctuations and dyskinesias unsatisfactorily managed with conventional medication. The outcome of non-motor symptoms - particularly affective and behavioral ones - following LCIG initiation remains scarcely explored, especially with respect to the changes undergone by oral dopaminergic drugs. Here we describe 4 PDpatients who developed dopamine agonist withdrawal syndrome (DAWS) symptoms correlated with rapid taper of these drugs after LCIG initiation. METHODS: We identified 4 cases developing apathy and depression after the rapid withdrawal of Dopamine agonists (DAs) consequent to LCIG introduction. The clinical data were obtained through detailed review of medical records. RESULTS: Within few days after DAs withdrawal, all 4 patients developed apathy, anhedonia and depression, despite the marked reduction of dyskinesias and the improvement of motor fluctuations after LCIG introduction. We unsuccessfully tried to manage these and other DAWS symptoms by increasing LCIG flow. Within 6 months, all patients spontaneously presented a slow but gradual improvement of DAWS symptoms, not requiring any further treatment strategy or LCIG discontinuation. CONCLUSIONS: To our knowledge, this is the first report describing the occurrence of DAWS symptoms in advanced PDpatients after DAs withdrawal in LCIG and highlighting the difficulty of distinguishing postoperative effects from drug withdrawal symptoms. Therefore we wish to draw attention of clinicians to the risk of developing DAWS in advanced PDpatients switched to LCIG monotherapy. In such cases, a rapid taper of DAs should be avoided.
Authors: Francesc Valldeoriola; María José Catalán; Francisco Escamilla-Sevilla; Eric Freire; Jesús Olivares; Esther Cubo; Diego Santos García; Matilde Calopa; Pablo Martínez-Martín; Juan Carlos Parra; Gloria Arroyo; José Matías Arbelo Journal: NPJ Parkinsons Dis Date: 2021-11-30