Direct Initiation of Levodopa–Carbidopa Intestinal Gel Infusion After a Positive Levodopa Challenge Test in Advanced Parkinson's Disease

Introduction: Levodopa–carbidopa intestinal gel (LCIG) is an established treatment option in advanced Parkinson's disease (PD). LCIG treatment is usually initiated with a nasojejunal tube (NJT) test phase before percutaneous endoscopic transgastric jejunostomy (PEG-J) tube installation. However, some centers have used direct initiation with PEG-J. Data comparing these approaches are scarce. The objective of this study was to analyze the risks and benefits of direct PEG-J initiation after a positive levodopa challenge test (LCT) for selected patients compared to initiation with a temporary NJT test phase. Methods: Thirty-three consecutive advanced PD patients commenced LCIG-treatment between February 2016 and December 2019 at Helsinki University Hospital. Of them, 11 (33%) selected patients had direct initiation without an NJT test phase. Treatment discontinuations and adverse events during the first 6 months of treatment were evaluated retrospectively. The duration of hospital stay related to the initiation of the treatment was compared between the groups. Results: Between the direct initiation and NJT test phase groups, there were no significant differences in treatment discontinuations (0 vs. 1, respectively); the number of inner tube or PEG-J tube replacements (1 vs. 3); or infection complications (1 vs. 3) during the first 6 months of treatment. Direct initiation significantly reduced the hospital stay related to treatment initiation (mean 7 vs. 9 days, p = 0.001). Conclusion: For selected patients, the direct initiation of LCIG after a positive LCT, without a temporary NJT test phase, appears safe and does not lead to additional treatment discontinuations or complications.