Enteral Feeding Using Levodopa‐Carbidopa Intestinal Gel Percutaneous Endoscopic Gastrostomy Tube

In Parkinson's disease (PD), dysphagia has a significant influence on nutritional status.1 When dysphagia is resistant to oral nutrition intervention, enteral nutrition using a percutaneous endoscopic gastrostomy (PEG) can be considered.2 A levodopa (l-DOPA)-carbidopa intestinal gel (LCIG) has been used to treat advanced PD using a PEG with a jejunal extension (PEG-J) (AbbVie, Montréal, Canada). We present a case in which the LCIG PEG-J was used successfully for feeding. A 71-year-old man treated with LCIG was referred because he suffered from recurring aspiration pneumonia. A swallowing evaluation showed moderate oro-pharyngeal dysphagia. Despite modified food textures, food enrichment, supplementation, and appropriate nutrition counseling, the patient experienced moderate-to-severe malnutrition. Enteral nutrition was initiated using a 15-Fr (5-mm) LCIG PEG-J through the gastric port. Nutrition was first administered with a feeding pump during the night while infusion of LCIG was stopped. To complement his nutritional intake, he received two boluses during the day. After a few weeks, as a result of sleeping discomfort, a new isocaloric enteral nutrition plan was established. Five boluses were administered with the feeding pump simultaneously with LCIG to mimic usual meal times. Before initiation of LCIG, in addition to 3 daily doses of entacapone, the patient received 1600 mg of l-dopa divided across 8 doses. He also received 200 mg of controlled-release l-dopa, which was continued after LCIG was initiated. LCIG was titrated to 100 mg/h for 16 hours with 3 to 4 additional 50 mg doses if needed. Enteral nutrition required no adjustment. As the enteral feeding and PEG-J ports are not compatible, an adaptor had to be crafted (Fig. 1). This modification reduced the size of opening to 8 or 9 Fr (2.7 to 3 mm), which did not allow for the administration of other pills because of increased obstruction risks. Therefore, the patient's PEG-J was changed for a larger caliber [20 Fr (6.7 mm); AbbVie, Montreal, Canada], which made medication administration possible. After a few months, enteral feeding had to be stopped because of severe gastroparesis and new episodes of aspiration pneumonia. The patient ultimately underwent jejunal feeding via surgically performed distal jejunostomy. This case illustrates that it is possible to use the LCIG PEG-J to administer enteral nutrition. Although enteral nutrition is infrequent in PD patients, the use of LCIG PEG-J can be an alternative when the usual nutritional interventions are unsuccessful in preventing malnutrition and aspiration pneumonia. For the LCIG PEG-J to become a viable route for enteral feeding, the development of an adaptor that makes enteral nutrition tubes and the LCIG PEG-J gastric port compatible is required. A 20-Fr caliber PEG is available and should be considered when LCIG is initiated for patients presenting moderate-to-severe dysphagia, as it allows for the administration of medication. Gastroparesis, which is frequent in PD, might be a limiting factor for gastric feeding.3 Protein-dopamine interaction may require medication adjustments,4 although no significant adjustment was necessary in this case. 1. Research Project: A. Conception, B. Organization, C. Execution; 2. Statistical Analysis: A. Design, B. Execution, C. Review and Critique; 3. Manuscript Preparation: A. Writing of the first draft, B. Review and Critique. A.B.: 1A, 1B, 1C, 3A, 3B J.D.: 1C, 3B B.G.: 1A, 1C, 3B C.L.: 1A, 1C, 3B N.J.: 1C, 3B V.S.: 1C, 3B M.P.: 1A, 1B, 1C, 3B S.C.: 1A, 1B, 1C, 3B A.D.: 1B, 1C, 3A, 3B Ethical Compliance Statement: We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. We confirm that the approval of an institutional review board was not required for this work. Funding Sources and Conflicts of Interest: A.D. is supported by a Canadian Institutes of Health Research (CIHR) clinician-scientist (Phase 1) training grant and was supported by a Parkinson Society Canada fellowship. S.C., J.D., B.G., C.L., and N.J. have served as advisers for AbbVie. Financial Disclosure for the previous 12 months: A.D. received an unrestricted educational grant from Actelion Pharmaceutiques Canada. A.D. received research grants from Ataxie Canada.

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