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Parkinson and Duodopa

By: Dr. Tania Gurevich, Adi Ezera, Movement Disorders Unit, Tel Aviv Medical Center.

As of January 2017, Duodopa treatment is included in the drug basket and is accessible to insured persons of all funds, regardless of supplementary insurances. The Parkinson's Association led the fight to introduce Duodopa into the health basket, to improve the accessibility of all patients to advanced treatments and for the quality of life of Parkinson's patients in Israel. The entry of Duodopa treatment into the health basket is great news for people suffering from Parkinson's. Good news that allows a simpler look into the future - knowing that even later, if and when the disease progresses, it will be possible to treat and maintain a good quality of life.

Duodopa treatment, manufactured by the Abbvie company, is intended for people with Parkinson's in an advanced stage of the disease and provides security for the future for patients, when the effectiveness of orally administered drugs decreases.

The treatment has been used in Israel for 8 years. During this time, a lot of experience was gained which allows to deal with the operation of the pump, balancing the patients in a good way and getting the best benefit from the treatment in order to provide a better quality of life for the patient.

What is duodopa?

Duodopa is a preparation in the form of a gel containing Levodopa + Carbidopa, identical in composition to Duficar/Cinemet but different in the way it is given to the patient.

The method of treatment is by instillation directly into the patient's intestine. The substance itself is inside a plastic container (cassette) that connects to a portable pump and from there to a tube that goes directly to the small intestine. Each cassette contains a sufficient amount for daily care and a low weight, about 450 grams (batteries and cassette).

How It Works? What is Daodopa's secret?

As Parkinson's disease progresses, the time of effect of each dose of pills is shortened. Thus, in order to create a prolonged effect on the patient to take a larger number of doses throughout the day. An increase in the dosage of the medication causes severe fluctuations in movement (dyskinesias), at the same time the duration of the "ON" time (time without involuntary movements) gets shorter and shorter until even adding another dose has no effect.

In addition, in Parkinson's patients, the emptying of the stomach is unpredictable and slow, therefore the effect of the drug treatment, which passes through the mouth to the stomach, cannot be predicted (that is, it is impossible to know when the medicine will start to work when the activity of the stomach is definitely not regular). As a result, we see fluctuations in the level of levodopa in the blood, which cause severe side effects.

Duodopa treatment is unique. Absorption of levodopa occurs in the upper part of the intestine, not in the stomach. By infusing levodopa directly into the small intestine, it is possible to bypass the stomach and thus provide a regular, safe and stable supply of dopa. Continuous administration of levodopa directly into the intestine, during all waking hours using a pump that is easy and convenient to carry allows the patient to continue his daily routine and his normal lifestyle - in a predictable, well-planned and known way, without "surprises".

It is also important to note that this form of administration is the closest to physiological dopamine stimulation, the situation most similar to natural stimulation.

From several years of experience and follow-up with most patients, this treatment replaces treatment with additional drugs for Parkinson's and allows maintaining a good, more stable quality of life and allows for a better sense of control over the disease and its consequences. According to studies, the effectiveness of duodopa treatment is maintained even with prolonged use, and over the years the dose may even decrease and normal function is maintained.

The improvement in the patient's condition naturally also allows improvement for the couple, the family and the caregivers.

Who is the treatment suitable for?

  • - Duodopa treatment may be suitable for a patient with Parkinson's disease in its advanced stages, a patient suffering from pronounced motor fluctuations and dyskinesia.
  • - A good response to Duficar is the main predictor of a good response to Duodopa.
  • - In order to benefit from the duodopa treatment, there is the need to insert a PEG through gastroscopy. This fact causes concern among various patients. However, it is important to know that before making the decision, a duodopa test can be performed by inserting a thin probe and infusing the substance. This test makes it possible to understand the effectiveness of the treatment without going through a complicated procedure and to make the decision regarding the treatment after its effectiveness has been tested.

What must be done to be treated with duodopa?

  1. Recommendation of the attending physician that the patient is indeed suitable for treatment.
  2. Explanation by the doctor to the patient and his family members about the treatment and use of the pump.
  3. Hospitalization of 3-4 days in order to adjust doses individually for each patient according to his condition. During the hospitalization, the patient is given the opportunity to experience the change and improvement in his function and the feasibility of the treatment even before the insertion of the permanent tube. This experiment is done by inserting a thin tube which reaches through the nose into the intestine (probe) and through which the substance is infused. The tube does not interfere with eating or drinking.
  4. After the dose specifically adapted to the patient has been determined, the procedure of inserting the fixed tube through a small opening in the abdominal wall, which is passed through the stomach directly to the intestine, is carried out. The operation is done under partial anesthesia by an experienced gastroenterologist. Immediately after that, connect the tube to the pump and you can start infusing the medicine. As with any interventional procedure, here too there is the possibility of inflammation or infection in the area where the tube is inserted, therefore it is important to maintain the hygiene of the place by washing daily. However, the percentage of complications is low and it is important to remember that in relation to improving the patient's quality of life - the benefit exceeds the price.

The pump is easy to operate, has convenient, clear and easy-to-use keys.

Throughout the entire process, the patient is accompanied by the hospital staff, but also by a brother/nurse (on behalf of the Abbvie company), the experts in Duodopa treatment. During hospitalization, the patient and his family will receive training on how to operate and care for the pump and will receive answers to questions that arise along the way.

  1. At the end of the hospitalization, the patient will return to his home and will be able to contact and consult with the treating staff if necessary.

Life with Duodopa

The treatment is given as a daily treatment for 16 hours (at night the patient disconnects from the pump).

Throughout the day there are three options for administering the medicine: Morning dose, Continuous dose, Extra dose, which help adjust the dose according to the need that arises during the day.

  • - Morning dose - the morning dose - a slightly larger dose than the regular dose given when waking up. The patient connects to the pump and presses the appropriate key.
  • - Continuous dose - the continuous daily dose, a fixed dose given continuously throughout the hours of connection to the pump.
  • - Extra dose - an extra dose that allows better control of symptoms. This dish has two purposes:
  1. If the patient wants to disconnect from the pump for a while (to bathe, swim or exercise).
  2. If the patient feels that he is about to enter OFF mode, he can add a small supplement to himself immediately by pressing a single button on the appropriate button. The addition of a small dose allows control of the dose taken by the patient and enables a return to normal function quickly without significant dyskinesias. This addition is only 2 mg compared to adding 1/4 or 1/2 a pill which means an addition of 50-100 mg.

FAQ

Is the weight of the pump significant and difficult?

From the accumulated experience, there are few patients who mentioned the weight of the pump as a difficulty. There is a large selection of comfortable means of carrying (on the shoulder, back or waist) and everyone manages to find the right one for them.

Is there an addiction (is it possible to become addicted to treatment)?

Experience shows that there is an increase in the total dose of dopa that the patient receives, the increase in dose allows for an improvement in motor and non-motor function and quality of life without aggravation of involuntary movements. Studies have shown that the effectiveness of the treatment is maintained even with prolonged use.

This is an innovative treatment, what is the experience in Israel?

Duodopa treatment came into use in Israel in 2009 (in this year the first patient was treated with Duodopa as part of a large international clinical study called Horizon). Since then we have gained a lot of experience and we know how to deal with the operation of the pump and how to balance the patients in a good way and get the best benefit from it so that it can allow the patients a better quality of life.

How is the absorption through the pump different from the pills?

DUODOPA = Levodopa + Carbidopa These are the same components found in Dufikar/Sinemet, but by the pump the treatment is given continuously and directly to the absorption site of the drug in the intestine. Since the preparation is in the form of a gel and reaches the intestine directly, it is possible to carry out a treatment of continuous dopaminergic stimulation - a form considered the most innovative in Parkinson's disease because it maintains a constant level of levodopa in the blood, similar to a healthy person.

In conclusion:

Duodopa treatment is an innovative treatment whose entry into the health basket is good news for advanced Parkinson's patients.

From experience and follow-up of several years, in most patients, this treatment replaces treatment with additional drugs for Parkinson's. and allows maintaining a good, more stable quality of life and allows a better sense of control over the disease and its consequences.

The treatment with Deodopa is customized for each patient in terms of dosage, installation and accompaniment along the way. It is possible to examine its effectiveness even before making decisions about invasive treatment, even though this treatment has been found to have a very low risk.

According to studies, the effectiveness of the treatment with daudopa is maintained even with prolonged use, and over the years the dose may even decrease and the normal function is maintained.

The use of Duodopa allows an improvement in the patient's quality of life, in his daily functioning over time.

The improvement in the patient's condition naturally also allows improvement for the couple, the family and the caregivers.