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Surgical Alternatives to Receiving Carbidopa/Levadopa


Carbidopa/levodopa enteral suspension (branded under the name Duopa in the U.S. and known as Duodopa outside of the U.S.) is a Parkinson's medication delivery system for people experiencing persistent ON-OFF fluctuations, especially those with advanced Parkinson's. A carbidopa/levodopa gel suspension is delivered through a surgically implanted tube directly into the small intestine, where the medication is absorbed. This medication delivery directly into the small intestine has the added benefit of bypassing the stomach, the emptying of which can become unpredictable or delayed for people with Parkinson's. The small pump which you carry or wear, allows infusion of a constant medication dose over 16 hours each day, with your physician's ability to prescribe additional doses at certain times.


​Research shows that carbidopa/levodopa enteral suspension reduces OFF time and increases ON time by almost two hours a day compared to carbidopa/levodopa pills. This effect was especially noted after four weeks of therapy and persisted over 12 weeks in a study of 71 people with Parkinson's.


​Carbidopa/levodopa enteral suspension can improve motor fluctuations by delivering continuous doses of carbidopa/levodopa. Dyskinesia can still occur, although it may be reduced in many cases as medication delivery levels out. The total daily dose of carbidopa/levodopa needed using carbidopa/levodopa enteral suspension may be less than that for pills.


​Like all therapies, there are potential downsides to enterally administered carbidopa/levodopa. The majority of these are seen within the first two weeks following the surgical procedure. The tube may become clogged or kinked, and there may be an infection around the insertion site. Once the tube is in place and the insertion site is suitably healed, a careful titration process ensures that the medication levels are just right for you.

People with mild Parkinson's symptoms who respond well to oral medication don't need to proceed with enterally administered carbidopa/levodopa. Additionally, anyone who is unmotivated, non-compliant, or has poor care partner support may have difficulty managing the logistics of storage, delivery of the cassettes, and the pump's operation. Finally, the medication is expensive, and health insurance coverage may be an issue.


​Common FAQs about Duopa Therapy

The Parkinson Foundation has put together a list of common FAQs about Infusion Therapy for advanced PD as published in their Surgical Options Guide.

Am I a good candidate for Duopa therapy?

You might be a good candidate for Duopa therapy if you

  • Have symptoms that respond to caribidopa/levodopa - even if only for short periods throughout the day

  • Experience daily motor fluctuations (changes in your ability to move) with three or more hours of "off" time.

  • Have tried and failed to control your motor fluctuations by adding and adjusting medications

  • You may be a good candidate for Duopa if you have gut issues, such as slow emptying of the stomach or constipation, or have difficulty with your meals interfering with the absorption of your levodopa.

​What does Duopa treat?

Duopa treats bradykinesia (slowness), rigidity (stiffness) and tremor. It generally helps PD symptoms that improve with your best medication "on" time when taking the pill form of carbidopa/levodopa. It may be helpful in reducing "on/off" fluctuations and other motor complications, like dyskinesia.


​Will I still need to take my other PD medications?

The pump is worn for up to 16 hours per day. In rare cases, it's used for 24 hours, for example, when levodopa throughout the night is needed to help sleep quality. Your continuous rate settings will provide most of your daily medication, and you may give yourself extra doses with the pump if needed. Some people continue their other PD medications, such as dopamine agonists or amantadine, although it is common to stop these medications once you have the pump. At night, you can expect to take your medication in pill form as normal.


​Can I swim or bathe with Duopa?

You can shower within two days of the procedure if the stoma is healing well- just disconnect the pump and avoid getting the pump wet. You will be able to swim and bathe with Duopa once your stoma heals, which normally takes several months. Your pump cannot get wet, so you will need to remove it prior to swimming or bathing. Your neurologist may advise you to give yourself an extra dose before you remove the pump. After swimming in a pool, make sure to wipe off the tubing to remove excess chlorinated water. Talk to your gastrointestinal (GI) specialist prior to swimming for additional information about how to keep your tube clean. Swimming alone is not recommended for people with Parkinson's due to the risk of drowning because of freezing.


​How expensive is Duopa Therapy? Will my insurance cover the costs?

Most insurance companies pay for Duopa therapy. However, since Duopa is relatively new in the United States, it is available as a name brand drug only - not generic. Out of pocket costs will differ from one insurance plan to another. Obtaining insurance coverage for Duopa may be more difficult if you are living in a long-term care facility. Before deciding whether Duopa is right for you, talk with your doctor and your insurance provider about what you can expect to pay per month and per year. Know that "copay assistance" is not always guaranteed to continue from year to year and is different than the "free drug program" available to some people. Ask your doctor if there is a social worker, pharmacy counselor or financial advisor who can help you make an informed decision.


​Will my pump activate the metal detector at the airport?

Yes, you will need to let the TSA agent know that you have a medical device and cannot go through the medical detector. Most airports will make special accommodations for people with medical devices and will allow them to bypass the metal detector. Ask your doctor for a letter explaining your need for the Duopa pump and print out a TSA Notification Card In addition, bring your Parkinson's Foundation Aware in Care Kit containing tools to keep you safe while traveling or during a hospital stay. The kit includes a medical alert card that you can share with security personnel that explains the pump and how it may be affected by the detector.


​Why would I pick Duopa instead of deep brain stimulation (DBS)?

Whether you choose Duopa or DBS is a decision that should be discussed with your neurologist and care team. In some cases when brain surgery is too risky, Duopa can be a reasonable alternative. Some people choose Duopa over DBS because it reduces their daily pill requirement. There are some people who have both DBS and Duopa, so it is important to remember that having one does not rule out the other.


​How important is having a reliable care partner if I choose Duopa?

People with Duopa and the experts who manage their care emphasize the importance of having an actively involved care partner. Duopa requires tubes and hardware that live outside of the body and need to be maintained (unlike DBS).


​Disclaimer: The information found within the Surgery section of the Parkinson Association of Alabama Parkinson's Disease Resource Center is for educational and awareness purposes only. The PAA does not condone nor endorse any specific procedure or medical product. Discussion about whether you are a candidate for a surgical procedure should be discussed between you, your care partner, and your medical team.


​Sources:

Surgical Therapies- Chapter 8. Page 138. Every Victory Counts, Davis Phinney Foundation for Parkinson's. Your Go-To Resource of Essential Information and Inspiration for Living Well with Parkinson's.


​Parkinson's Foundation. Surgical Options. Infusion Therapy for advanced PD, Page 54-57. "Booklet." 2022


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