What are dyskinesias and how are they managed?

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May 29, 2024

What are dyskinesias and how are they managed?

Dyskinesias are involuntary, erratic, and often writhing movements that can affect various parts of the body, including the face, arms, legs, and trunk. They are a common complication of long-term levodopa therapy in Parkinson’s disease (PD) and can significantly impact the quality of life. Here’s an in-depth look at dyskinesias and their management:

1. Types of Dyskinesias

Peak-Dose Dyskinesias:

  • Occur when the concentration of levodopa in the blood is at its highest, usually after taking a dose.
  • These are the most common type of dyskinesias in PD patients.

Diphasic Dyskinesias:

  • Occur at the beginning and end of a dose cycle when the medication levels are rising or falling.
  • They are typically less common and can present as repetitive, rhythmic movements.

Off-Dystonia:

  • Occurs when the medication effect is wearing off, leading to sustained muscle contractions that can be painful and disabling.
  • Often affects the feet and toes but can also occur in other body parts.

2. Causes of Dyskinesias

Levodopa Therapy:

  • Long-term use of levodopa, particularly in high doses, is the primary cause of dyskinesias in PD patients.
  • As PD progresses, the brain’s ability to buffer dopamine diminishes, leading to fluctuations in dopamine levels and subsequent dyskinesias.

Disease Progression:

  • The loss of dopaminergic neurons and changes in brain circuitry contribute to the development of dyskinesias.

3. Management Strategies

a. Medication Adjustments:

Levodopa Dose Fractionation:

  • Dividing the total daily dose of levodopa into smaller, more frequent doses can help maintain more stable blood levels and reduce peak-dose dyskinesias.

Extended-Release Formulations:

  • Using extended-release formulations of levodopa (e.g., Rytary) to provide a more consistent delivery of medication over time.

Adding Adjunctive Medications:

  • Amantadine: An NMDA receptor antagonist that can reduce dyskinesias. Extended-release amantadine (Gocovri) is specifically approved for this purpose.
  • MAO-B Inhibitors: Medications like selegiline and rasagiline can help smooth out motor fluctuations and may indirectly reduce dyskinesias.
  • COMT Inhibitors: Drugs like entacapone and opicapone can prolong the effect of levodopa, helping to stabilize dopamine levels.
  • Dopamine Agonists: These medications can provide continuous dopaminergic stimulation, potentially reducing the need for high doses of levodopa.

b. Advanced Therapies:

Deep Brain Stimulation (DBS):

  • Surgical implantation of electrodes in specific brain areas (usually the subthalamic nucleus or globus pallidus internus) to provide continuous electrical stimulation.
  • DBS can significantly reduce dyskinesias and improve motor control by modulating abnormal brain activity.

Levodopa-Carbidopa Intestinal Gel (LCIG) – Duodopa:

  • Continuous infusion of levodopa-carbidopa gel directly into the small intestine via a portable pump, providing a steady delivery of medication and reducing motor fluctuations and dyskinesias.

c. Non-Pharmacological Strategies:

Physical Therapy:

  • Exercise and physical therapy can help improve overall mobility and reduce the impact of dyskinesias on daily activities.

Dietary Adjustments:

  • Spacing protein intake away from levodopa doses to enhance the absorption and effectiveness of the medication.

Lifestyle Modifications:

  • Maintaining a structured daily routine and minimizing stress, which can exacerbate dyskinesias.

4. Monitoring and Follow-Up

Regular Assessment:

  • Continuous monitoring by healthcare providers to adjust treatment plans based on the patient’s response to medications and the severity of dyskinesias.

Patient Education:

  • Educating patients and caregivers about dyskinesias, their triggers, and management strategies to improve self-care and quality of life.

Conclusion

Dyskinesias are a challenging and common complication of long-term levodopa therapy in Parkinson’s disease. Effective management involves a combination of medication adjustments, advanced therapies, and supportive non-pharmacological strategies. Regular monitoring and individualized treatment plans are essential to minimize the impact of dyskinesias and improve the overall quality of life for individuals with Parkinson’s disease. Collaboration between neurologists, movement disorder specialists, and other healthcare providers is crucial to providing comprehensive care for patients experiencing dyskinesias.


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