DUODOPA® (Levodopa/Carbidopa Intestinal Gel) THERAPY

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Location

Toronto Western Hospital | Map iconMaps & Directions

Assessment for Duodopa® therapy is performed in the Duodopa® Clinic at Toronto Western Hospital. This clinic is a part of The Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic.

It is located in the McLaughlin Pavilion – 7th Floor.

Patients deemed appropriate for Duodopa® therapy have insertion of the percutaneous endoscopic transgastric jejunostomy (PEG-J) performed in the Endoscopy Unit. This is an outpatient procedure held on the 4th floor East Wing. Initiation and titration of Duodopa® medication occurs approximately two weeks post PEG-J insertion at the Duodopa® Clinic on the 7th floor McLaughlin Pavilion.​​​

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What We Do

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 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).

KNC Duodopa

After your assessment at the Duodopa® clinic is complete, your neurology team will:

  • Discuss whether your condition and needs can be helped with Duodopa® therapy
  • Provide a demonstration of the PEG-J, pump, and medication cassette
  • Discuss the risks and benefits of the therapy and answer any questions you may have
  • Depending on your symptoms, you may have to undergo the insertion of a temporary tube through your nose into your small intestine (nasojejunal tube) for a few days to see how you respond to Duodopa® before undergoing permanent therapy
  • If you agree to proceed with Duodopa®, we will seek approval through your insurance (if under 65) or Ministry of Health and Long-term Exceptional Access Program (if 65 or older)
  • Once we obtain approval (it usually takes about 4 weeks), you will be referred to one of the gastroenterologists

Gastroenterology Evaluation

A few weeks after you are referred to your gastroenterologist, you will meet him or her to:

  • Determine if the percutaneous endoscopic gastrostomy with J extension (PEG-J) insertion is possible
  • Discuss the risks and benefits of the PEG-J procedure
  • Explain the details of the procedure and answer any questions you may have
  • Sign a consent form

Once you have met the gastroenterologist, their office will contact you to schedule:

  • a Pre-Admission Clinic visit to help you prepare for the procedure
  • your PEG-J insertion date

How Duodopa® works

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:

  1. External PEG tube. Tube that leads from the pump through the abdominal wall and into the stomach.
  2. Internal J tube. Tube that is placed within the PEG tube through the stomach and into the small intestine, delivering Duodopa®.
  3. CADD-pump.  The pump administers Duodopa® continuously into your small intestine. The continuous and direct administration into the small intestine contributes to providing a more constant amount of drug into your body through the day.
  4. Medication cassette. A plastic container that holds the Duodopa® gel. This is connected to the pump and contains the equivalent of 20 tables of 100mg Levodopa (2000mg total) and 25mg Carbidopa (500mg total). The cassette has to be stored in the fridge and should be changed once a day (rarely twice).

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.


Duodopa® ​Requirements

In order to qualify for Duodopa®

  • You must have at least 25% "off" time during the waking day;
  • Used a maximum amount of oral levodopa with good response;
  • Tried other adjunctive Parkinson's medications (entacapone, dopamine agonists, monamine oxidase-B inhibitors) without sufficient benefit; and
  • Not experiencing uncontrolled psychosis or severe dementia.

Contacts

Neurologists

Dr. A. Lang 

Phone: 416 603 5800 ext. 6422

Dr. A. Fasano

Phone: 416 603 5800 ext. 5729

Nursing Team

Phone: 416 603 5800 ext. 2637​​​