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Vol. 38. Issue 3.
Pages 220-221 (April 2023)
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Vol. 38. Issue 3.
Pages 220-221 (April 2023)
Letter to the Editor
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New-onset impulse control disorders after treatment with levodopa–carbidopa intestinal gel in Parkinson's disease
Trastornos del control del impulso de nueva aparición como complicación del tratamiento con gel intestinal de levodopa-carbidopa en la enfermedad de Parkinson
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A. Contreras Chicotea,
Corresponding author
anacontreraschicote@hotmail.com

Corresponding author.
, G. Velilla Alonsoa, M. Mas Serranoa, F. Grandas Pereza,b
a Neurology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b School of Medicine, Universidad Complutense de Madrid, Spain
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Dear Editor:

Impulse control disorders (ICDs), are a serious and increasingly recognized complication in Parkinson's disease (PD), occurring in up to 20% of patients.1 ICDs have been mostly related to the use of dopamine agonists (DAs). However, ICDs have also been reported to occur with levodopa, monoamine oxidase inhibitors, and amantadine treatment, as well after deep brain stimulation.1,2

Levodopa treatment has been associated with compulsive behaviors such as punding and dopaminergic dysregulation syndrome.3,4

Levodopa–carbidopa intestinal gel (LCIG) is a treatment that has been reported to be beneficial in patients with advanced Parkinson's disease. LCIG treatment can reduce OFF periods and improve motor as well as non-motor symptoms.5,6

Switching patients with advanced PD from oral medications to LCIG has been reported to improve IDCs. More stable plasma levels of levodopa and discontinuation of dopamine agonist are thought to underlie the improvement.2

We here report our experience regarding two patients with advanced Parkinson's disease who developed a de novo ICD with LCIG.

Case 1. A 70-year-old male with advanced Parkinson's disease that had started ten years ago and that was complicated with motor fluctuations. Treatment with LCIG was initiated, resulting in a reduction in OFF periods of >50%. The initial dose of levodopa was 1340mg per day (before LCIG the equivalent dose of levodopa was 1500mg/day). No extra doses were administered and no other concomitant oral medication was necessary. After a month, the patient developed hypersexuality that manifested as an increased sex drive. They had not exhibited this abnormal behavior previously. Initially, quetiapine up to 100mg/day was added. In later weeks, it became necessary to reduce the levodopa doses. As the patient experienced motor deterioration, the total dose of levodopa was increased again to 1400mg/day, which resulted in continued hypersexuality. Ultimately, the LICG was withdrawn two years later because the patient developed cognitive impairment.

Case 2. A 58-year-old patient who for the past 12 years had suffered from Parkinson's disease that was complicated with wearing off-type motor fluctuations with more than 15h of OFF periods. Before LCIG, the equivalent dose of levodopa was 1200mg/day. LCIG treatment was started and resulted in a good motor response. The initial dose of levodopa was 1246mg/day and pramipexole was maintained at 0.52mg/day. One month later, the pramipexole was withdrawn due to choreic dyskinesias. Six months later, the patient developed a pathological gambling behavior and hypersexuality: he started playing Bingo and visiting brothels on a daily basis. Initially, the daily dose of levodopa was reduced. However, as this resulted in motor deterioration, quetiapine was added. At present, after five years of LCIG treatment, the patient still suffer from ICD and finally was institutionalized.

There is experience in the literature of new-onset ICDs after the initiation of LCIG.7 The ICDs in our cases arose with levodopa monotherapy (>1000mg in both cases) and with no personal history of previous ICDs. Reductions in the levodopa doses were not possible and quetiapine could only partially control the ICDs.

The high doses of levodopa achieved with LCIG do not fully explain the occurrence of ICDs. It is possible that a personal susceptibility promotes the development of such behaviors, and prospective studies are needed to investigate whether there may be an increased risk of ICDs with LCIG treatment.

Funding

The authors declare that there is no financial support or competing interests regarding this manuscript.

The authors state that the current manuscript has not been presented at a professional meeting. Patient consent was obtained for publication of the case report.

Author contributions

ACC, GVA and MMS have collected the data and written the draft of the manuscript. FGP has reviewed and approved the manuscript. All authors approved the final draft for submission. FGP is the article guarantor.

Conflict of interest

The authors declare no conflict of interest.

Acknowledgements

None.

References
[1]
D. Weintraub, J. Koester, M.N. Potenza, et al.
Impulse control disorders in Parkinson disease: a cross-sectional study of 3090 patients.
Arch Neurol, 67 (2010), pp. 589-595
[2]
A. Todorova, M. Samuel, R.G. Brown, K.R. Chaudhuri.
Infusion therapies and development of impulse control disorders in advanced parkinson disease: clinical experience after 3 years’ follow-up.
Clin Neuropharmacol, 38 (2015), pp. 132-134
[3]
E.M. Gatto, V. Aldinio.
Impulse control disorders in parkinson's disease. A brief and comprehensive review.
Front Neurol, 10 (2019), pp. 351
[4]
J.A. Molina, M.J. Sáinz-Artiga, A. Fraile, et al.
Pathologic gambling in Parkinson's disease: a behavioral manifestation of pharmacologic treatment?.
[5]
F.C. Chang, V. Kwan, D. van der Poorten, et al.
Intraduodenal levodopa-carbidopa intestinal gel infusion improves both motor performance and quality of life in advanced Parkinson's disease.
J Clin Neurosci, 25 (2016), pp. 41-45
[6]
H. Honig, A. Antonini, P. Martinez-Martin, et al.
Intrajejunal levodopa infusion in Parkinson's disease: a pilot multicenter study of effects on nonmotor symptoms and quality of life.
Mov Disord, 24 (2009), pp. 1468-1474
[7]
W.A. Kamel, J.Y. Al-Hashel.
LCIG in treatment of non-motor symptoms in advanced Parkinson's disease: review of literature.
Brain Behav, 10 (2020), pp. e01757
Copyright © 2022. Sociedad Española de Neurología
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