Combining Device‐Aided Therapies in Parkinson's Disease: A Case Series and a Literature Review

Background Deep brain stimulation (DBS), levodopa‐carbidopa intestinal gel (LCIG) and subcutaneous apomorphine infusion are device‐aided therapies (DATs) for advanced Parkinson's disease (PD). We present a case series from the Cretan PD Registry who required 2 DATs for optimal management along with a systematic review of similar studies. Cases From 2009 to 2020, we retrospectively studied all PD patients who were simultaneously treated with 2 DATs. Six patients on DBS required an infusion treatment for persisting or re‐emergent fluctuations because of disease progression. Two patients on LCIG infusion received DBS as a levodopa‐sparing strategy because of drug‐induced complications. Fluctuations and quality of life improved in all patients. Literature review We identified 4 case series, 1 prospective and 1 retrospective study that included a total of 50 DBS‐treated patients who required an infusion therapy. Improvement in motor outcomes, assessed in different ways, was a constant finding. Conclusions Selected PD patients on 1 DAT may experience additional benefit from a second DAT, for several reasons along the course of their disease. Although infusion therapies optimize dopaminergic drug delivery in fluctuating DBS‐treated patients, DBS added on LCIG treatment has an additive symptomatic effect that allows levodopa dose reduction in patients with drug‐induced side effects.