Levodopa/carbidopa intestinal gel infusion long-term therapy in advanced ParkinsonÕs disease D. Nyholm a , K. Klangemo a and A. Johansson a,b a Department of Neuroscience, Neurology, Uppsala University, Uppsala; and b Department of Neurology, Karolinska University Hospital, Stockholm, Sweden Keywords: carbidopa, infusion, levodopa, long-term, ParkinsonÕs disease Received 1 November 2011 Accepted 19 January 2012 Background: Infusion of levodopa/carbidopa intestinal gel (Duodopa Ò ; Abbott) was introduced in Sweden in 1991 as an experimental treatment in advanced ParkinsonÕs disease and obtained EU approval in 2004. There is compelling evidence for short- term use of this treatment; however, long-term data are scarce. Methods: A retrospective review of medical records was performed. The primary objective was to assess the duration of treatment for all Swedish patients starting long-term levodopa/carbidopa gel therapy between January 1991 and June 2008. Secondary aims were to study demographics, treatment with anti-ParkinsonÕs disease drugs and other concomitant medications, and reasons for discontinuation of levodopa/carbidopa gel. Results: Of 150 identified patients, 135 were included in the study. On average, patients were 49 years at diagnosis of ParkinsonÕs disease and 63 years when infusion therapy was initiated. The median treatment time on infusion was 3.4 years (range, 0–16 years). The restricted mean treatment time was nearly 8 years; 81 patients were still on treatment at the end of the study. Levodopa was used as monotherapy in a majority of patients. Dosage of the drug was stable over time. Thirty-one patients discontinued infusion prior to the cutoff date and 23 patients died. Device-related problems were the most common reason for discontinuation. Patients were more likely to discontinue infusion therapy before 2000. The year of infusion initiation was significantly earlier in the dropout group compared with a matched group of continuing patients. Conclusions: Levodopa/carbidopa intestinal gel infusion is a long-term treatment alternative in patients with advanced ParkinsonÕs disease. Introduction The complexity of levodopa therapy in ParkinsonÕs disease (PD) becomes apparent during long-term ther- apy with the drug. Many patients with PD develop motor fluctuations and dyskinesias after months to years of levodopa treatment [1]. Additionally, axial motor symptoms become more pronounced, and non- motor symptoms may substantially contribute to im- paired quality of life [2]. Not all of these late-stage symptoms respond to levodopa; however, because levodopa is the most effective therapy in PD, the opti- mization of levodopa dosage is extremely important [3]. Currently, the most sophisticated way of optimizing levodopa therapy is by means of intraduodenal infusion of a levodopa/carbidopa gel [4,5]. This infusion pro- vides stable concentrations of levodopa [6] and, there- fore, stability in motor and non-motor symptoms, as compared with conventional therapy [7–9]. However, the infusion system may cause technical complications [8], and there have been recent reports on the devel- opment of axonal neuropathy during levodopa/carbid- opa gel infusion [10]. Therefore, long-term outcome is of great interest, but so far, is limited [11]. The infusion therapy was introduced in Sweden in 1991 as an experimental treatment on compassionate use. It was approved in EU in 2004. The therapy is tried out for a few days using a temporary nasojejunal tube and is administered long term using a percutaneous endo- scopic gastrojejunostomy. During the period from January 1991 to June 2008, approximately 150 patients were treated long term, with the levodopa/carbidopa infusion gel in Sweden. The aim of this retrospective study was to assess the nationwide duration of Correspondence: D. Nyholm, Department of Neuroscience, Uppsala University, SE-75185 Uppsala, Sweden (tel.: +46 18 6115038; fax: +46 18 6115027; e-mail: dag.nyholm@neuro.uu.se). Ó 2012 The Author(s) European Journal of Neurology Ó 2012 EFNS 1 European Journal of Neurology 2012 doi:10.1111/j.1468-1331.2012.03679.x