Localization Matters: Impacts of PEG-J Localization in Intestinal Levodopa Therapy for Parkinson's Disease

Real-world clinical evidence is missing to understand the resorption characteristics of levodopa through duodenal and jejunal parts of the small intestine.

To characterize how different application sites of intestinal levodopa gel would impact on levodopa dosing and clinical outcomes.

This multicentre retrospective analysis investigated Parkinson's disease patients (n = 111) and their change in levodopa equivalent dosage when switching from oral treatment to intestinal continuous infusion therapy while stratifying for differences in percutaneous gastrojejunostomy (PEG-J) tube localizations. We analyzed data from patients treated with both levodopa-carbidopa (LCIG) and levodopa-carbidopa-entacapone (LECIG) intestinal gel.

In dichotomic analysis, duodenal and jejunal tube positions showed similar levodopa equivalent dosages changes from baseline (P = 0.143). This was similar when subdividing patients for LCIG and LECIG treatment. In duodenal PEG-J positions, 44.4% of patients showed persistent motor fluctuations compared to 21.9% in jejunal placements (P = 0.026). In duodenal positions, fluctuations most often persisted when the PEG-J tube was placed proximally into the duodenum. In jejunal localizations, several patients displayed a satisfactory outcome from the primary intervention but experienced dislocation of the PEG-J tube to a duodenal position. This was associated with re-emergence of motor fluctuations in a majority of them.

Our real-world data suggest that LCIG and LECIG are absorbed similarly in both duodenal and jejunal portions of the small intestine. However, clinical data suggest, that jejunal positioning is critical to the stabilization of dopaminergic motor fluctuations.