Medication pumps (Duodopa® or Lecigon®)
This is a procedure that is used exclusively for Parkinson’s patients. Pump therapies can be used to ensure that a drug therapy has a continuous effect in the brain. This is a major advantage over pills, which are taken every few hours and develop correspondingly unstable active levels in the brain. Parkinson’s patients often suffer from this so-called “pulsatile” treatment during the course of the disease, which manifests itself with alternating under- and over-movements at low and high concentrations in the brain.
In addition, many Parkinson’s sufferers do not have reliable gastric emptying, which leads to unreliable absorption of the medication and further exacerbates the problems.
Pump therapies therefore continuously deliver medication available in liquid or gel form via various routes into the bloodstream and thus into the brain. The intrajejunal levodopa pump applies the medication directly into the small intestine, where the medication is absorbed.
With the apomorphine pump, the medication is delivered into the subcutaneous fatty tissue via a small needle. The procedure is suitable for Parkinson’s patients with severe motor fluctuations and excessive movements that cannot be treated satisfactorily with available combinations of antiparkinsonian drugs.
In principle, pump therapy is no less effective than deep brain stimulation in the “Parkinson’s core”. Both forms of therapy aim to improve the fluctuations and stabilize the effect of the medication. An important difference lies in the tremor. This may be better treated with deep brain stimulation than with the pump.
The main difference between DBS and pump therapies lies in the everyday handling. This is more cumbersome for most people affected by pump therapies, as it is a device that is worn on the outside of the body and has to be cared for accordingly. An intact social environment is important: the operation and care of the pump must be guaranteed. There are differences in the size and weight of the various pump systems depending on the composition of the medication. They are offered by various manufacturers, but all of them provide an excellent patient service in the home environment.
Levodopa pumps
Test phase
During the test phase, patients and their relatives can decide together with the treating physicians whether pump therapy should be definitively established. For this purpose, the medication is not administered directly via a tube through the abdominal skin, but first via a nasogastric-small intestine tube. During the test phase, the response of motor and non-motor symptoms to constant levodopa therapy is tested, which leads to an improvement in motor function and quality of life.
Only in the latter case is a pump insert definitely pursued.
Intervention and determination of the dose
If the decision is made in favor of a definitive solution, the gastroenterologist inserts a so-called PEG-J – a percutaneous endoscopic gastro-jejunostomy. This is a thin tube that leads through the abdominal wall directly into the small intestine. The adjustment process then begins with the search for the optimum dose – initially in hospital, and later either in inpatient rehabilitation or at home. Employees from an external company provide our patients with intensive care during this important phase, both in hospital and at home. Risks and side effects
Psychiatric side effects such as hallucinations or hyperactivity may also occur with levodopa pump therapy. However, these can be remedied by adjusting the flow rate of the pump therapy and, if necessary, using additional medication.
The probe may also become blocked or displaced. This happens mainly due to lack of care or incorrect handling. Another problem with improper care is local hypergranulation. This means that a bulge forms around the puncture site on the abdomen.
It has also been described that the risk of polyneuropathy is increased during levodopa pump therapy. This is damage to the finest nerves that supply the feet and lower legs in particular. This can lead to gait instability. A vitamin B deficiency plays a particularly important role here. For this reason, blood B-vitamin levels should be tested regularly.
The Lecigon ® pump is slightly smaller and lighter than the Duodopa ® pump. This is achieved, among other things, by adding the additive entacapone to the gel, which enhances the effect of levodopa. The corresponding tablet, which contains the same additive, is called Stalevo ®. Some sufferers do not tolerate this additive and develop diarrhea, for example. A treatment trial with Stalevo should therefore be carried out prior to Lecigon-Pumpen ® therapy to see whether the additive is tolerated.
Apomorphine pump
In contrast to the levodopa pump, with the apomorphine pump the medication is not injected into the small intestine but under the skin. This is used to treat Parkinson’s patients who have motor fluctuations despite individually adjusted treatment with levodopa and/or dopamine agonists.
The treatment procedure is also essentially the same as for the levodopa pump. However, the test phase with direct administration under the skin is easier to carry out and the intervention by the gastroenterologist is not necessary. The dose is also adjusted at the beginning of this therapy until the optimum treatment is achieved.
With regard to risks and side effects, there are no potential problems associated with the probe system. With apomorphine therapy, however, there is a possibility of malaise, increased tiredness and low blood pressure, especially at the beginning. Psychological changes are also more likely to occur. Nodules may form locally at the puncture sites on the abdomen.
Recent studies show that such skin nodules, which can become painful over time, occur in over 40% of patients after just a few months.
