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Duodopa® is a treatment for advanced Parkinson's disease offered to patients when various combinations of Parkinson's medications are no longer sufficient to provide a good quality of life. For example, when the many doses of oral levodopa taken by the patient fail to keep them in their best state of mobility for enough of the waking day Duodopa® may be considered.
It can be used for Parkinson's disease in people who are responsive to oral levodopa treatment, but have a substantial amount of "off" time without satisfactory control of severe, disabling motor and non-motor symptoms despite multiple doses of currently available oral medications. This treatment will not improve symptoms that are unresponsive to levodopa.
Duodopa® is a gel mixture of levodopa and carbidopa administered throughout the day with a portable pump into the small intestine via a permanent tube that passes through the abdominal wall, the stomach and into the small intestine (PEG-J). It allows a constant amount of levodopa to be present in the blood, which can reduce motor fluctuations therefore, decreasing the number of times patients alternate between significant "off" time and uncontrolled movement (dyskinesia).
After your assessment at the Duodopa® clinic is complete, your neurology team will:
A few weeks after you are referred to your gastroenterologist, you will meet him or her to:
Once you have met the gastroenterologist, their office will contact you to schedule:
Duodopa® is administered throughout the waking day. The pump is connected in the morning and disconnected in the evening at bedtime. The Duodopa® system consists of 4 parts:
You will have a procedure done by the gastroenterologist to insert a combination of two tubes (PEG-J) through your stomach through the abdominal wall and into the small intestine. This is an outpatient procedure, and you will be discharged the same day. The day after the procedure, you will return to the clinic for evaluation of your PEG-J site.
Two-three weeks after PEG-J insertion, Duodopa® therapy will be initiated. The CADD-pump with the medication cassette will be attached to your PEG tube and over three consecutive days for 6-7 hours per day, you will be monitored at the Movement Disorders Clinic by your neurologist and nurse. The medication dosage will be titrated by your specialist team during this time. No hospital admission will be needed for these visits. The goal is to find the dose that gives you the best possible results. Dosing regimens are programmed into the pump on an individual basis.
In order to qualify for Duodopa®
You have your
pre-admission clinic appointment a few days or weeks before your surgery. This visit takes about 3 to 4 hours in order to obtain
CXR, a consultation with an anesthetist and the pre-admit nurse will review instructions on how to prepare for the PEG-J procedure.
Please bring the following with you:
If you cannot go to your procedure, call the gastroenterologist's office as soon as you know. Their office would have provided you with its contact information at your initial appointment.
Part of planning for PEG-J insertion is making arrangements for someone to:
Do not eat any food or drink after midnight the night before your procedure. Your stomach must be empty.
Please bring with you a list of your current medications. This includes prescription medications, over-the-counter medications, vitamin or mineral supplements and herbal remedies.
Take your Parkinson's medication as usual. They may be taken with sips of water unless your doctor instructs you otherwise.
Your doctor may not want you to take blood thinners or diabetes medications and will discuss this with you at an appointment before your procedure.
You will arrive at the Endoscopy Unit on the East Wing (4th floor) at your designated procedure time. Check-in at the reception desk and have the following ready:
After check-in, the receptionist will give you a name band to wear. The nurse will help you get ready for surgery. You will be asked to change into a hospital gown and given a locker to keep your valuables.
The nurse will check your blood pressure, pulse, temperature and breathing. They will also put an intravenous (IV) in your arm and administer antibiotics 30 minutes prior to PEG-J insertion. You are taken to the recovery room where you will meet the Anesthetist, who will give your anesthetic and monitor you during your procedure.
The procedure takes about 45-60 minutes. You will be taken to the Endoscopy procedure room where you will be greeted by the Gastroenterologist. You will lie flat and be given conscious sedation, a combination of medications to help you relax and remain comfortable.
The Gastroenterologist will:
When the procedure is finished, you will go into the Endoscopy Recovery room for 1-3 hours to recover.
You can expect to go home within a few hours after your PEG-J insertion once you have recovered from anesthesia.
Before you leave the hospital, we will:
You will return to the Movement Disorders Clinic at the McLaughlin Pavilion (7th floor) the following day after your PEG-J procedure.
During this appointment, you will see the gastroenterologist who inserted the PEG-J and your neurology nurse specialist. We will assess for complications such as pain and bleeding and check your stoma to ensure there are no signs of infections. We will remove the split gauze dressing and apply a Drain-Fix dressing that will stabilize the external portion of the tube and allow for the incision site to heal properly over the next few days. The nurse will also review instructions on proper stoma care and tube management.
Four days after the procedure, a nurse from the Shoppers Specialty Health Network AbbVie Care program will arrange to visit you at your home. The nurse will remove the Drain-Fix dressing and reinforce how to manage your stoma site.
At home, your medications will remain the same until Duodopa® initiation.
Look at your incisions every day and watch for these signs of infection:
If you notice any of these signs or symptoms, please tell your neurology nurse as soon as possible.
It is important to check mood and behaviour after PEG-J insertion and after Duodopa® titrations. You or your family members need to report any changes to your health care providers.
If you experience severe pain at the abdominal site, nausea and bleeding from the stoma please proceed to your local emergency department.
After PEG-J insertion is complete, you will remain on your normal PD medication regimen for the next 2-3 weeks. Once Duodopa® is initiated, it will continuously infuse levodopa/carbidopa gel to the small intestine. This helps relieve your PD symptoms during the daytime. At night, you will continue to take your regular PD medication.
Titration means determining the Duodopa® dose that controls your PD symptoms with the fewest side effects. Approximately 2-3 weeks after PEG-J insertion, Duodopa® titration will take place.
Titration is completed over a course of three days in the Movement Disorders Clinic until we find the dose giving you the best possible results.
Your neurology team will decide what PD medications you will remain on once Duodopa® is initiated. You will no longer take oral levodopa during the day and be instructed on how to slowly reduce your other PD medications.
Once you disconnect the pump in the evening, some patients will need to take additional medications during bedtime and overnight. Infusion of Duodopa® overnight can be considered depending on your symptoms.
In terms of Duodopa® adjustments, with the guidance of your neurology team you will be able to make changes to your pump and dosages from home.
After titration is complete to the best dosage, you will have a follow-up visit with the neurology team in 1 month and every 4 to 6 months thereafter. Relevant bloodwork will be completed during these visits at TWH.
You may have follow-up visits with the team if there are any issues related to the tubing and the stoma site.
An interventional radiologist may see you if there are complications related to the J-tube. They will be able to replace a blocked or displaced J-tube.
You can see your family doctor for issues related to the stoma site i.e. infections.
Designed specifically for delivery of Duodopa® and is NOT intended for IV or other routes of infusion. There is no known expiration date for the pump. If you are having any problems with your pump, we will supply you with a new one.
There is no specific timeframe for PEG-J replacement. Typically it is completed on a case-by-case basis and is dependent on its functionality.
The regular cassettes can be discarded in your regular household waste container or returned in a red plastic bag supplied by Shopper Specialty Health.
All your health care providers need to know that you have a PEG-J tube specific for Duodopa® infusion so that they can take steps to keep you safe.
You will be contacted with information about your first appointment.
Please bring the following to your appointment. Not all of these items may be needed for your appointment. Our clinic or your referring doctor will let you know what you must bring.
Please arrive 15 minutes before your appointment.
When you arrive, you will sign in with the receptionist. You will need your health card (OHIP card) to sign-in. If you do not have an OHIP card, please bring another form of government-issued photo ID, such as a driver’s license or passport.
You may be given a Measuring Health Equity Questionnaire to fill out. This form contains questions about your background. We collect this information to find out who we serve and what unique needs you may have. The form is voluntary and you can choose ‘prefer not to answer’ to any or all questions. However, the information you choose to give us will help us improve the quality of care for you and others.
First appointments take longer than follow-up appointments. Your first appointment can take 2 hours or more. Follow-up appointments usually take 15 to 30 minutes. We do everything we can to stay on time but sometimes unforeseen circumstances may delay your appointment.
At the end of your first appointment, the nurse or doctor will give you a contact list for your health care team. If you don’t get a contact list, feel free to ask for it.
After every appointment, a member of your health care team will tell you about your next visit. Be sure you understand what is going to happen next. For example, know the time and place of your next visit or if someone will call you with this information.
If you are unsure about what your next steps are, don’t be afraid to ask a member of your team. We are here to help you.
We understand that reaching us by phone can sometimes be difficult. Often our phone lines are busy or are turned over to the message centre so our staff can prepare for clinic visits or help other patients. We make every effort to return your call within 24 hours. Our staff will try to reach you 2 times. If we are not able to reach you directly you may need to call us again.