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Levodopa induced Dyskinesia
What are the most common types of Levodopa induced Dyskinesia (LID) and how are they treated?
After 3 years of treatment, approximately 50% of patients with Parkinsons Disease display some degree of involuntary movements related to levodopa.
Phenomenologically, Levodopa induced Dyskinesia may be classified into three main categories:
Peak-dose dyskinesias (improvement–dyskinesia–improvement, or I–D–I)
These coincide with the time of maximal clinical improvement and usually consist of choreiform movements. Such dyskinesias may improve with levodopa dose reduction.
• Diphasic dyskinesias (dyskinesia–improvement–dyskinesia, or D–I–D)
These occur at the onset and/or at the end of the “on” period during rising and falling levels of levodopa blood levels and usually consist of dystonia and repetitive stereotypic movements of the legs.
Some patients display a combination of the two types and have dyskinesia the entire “on” period (square-wave dyskinesias).
Such dyskinesias may improve with dose increments.
• “Off” dyskinesias
These are typically painful dystonias, coincide with the period of decreased mobility.
The most common example is early morning dystonia.
Dopaminergic stimulation increases “on” dyskinesias and decreases the other two types. Conversely, antidopaminergic drugs improve all forms of Levodopa induced Dyskinesia, although they worsen the Parkinsons Disease.
Dystonia induced by levodopa may improve significantly with either the use of baclofen, an agonist of gamma-aminobutyric acid (GABA) receptors, or local intramuscular injection of botulinum toxin. Amantadine may reduce dyskinesia without worsening Parkinsons Disease symptoms possibly via N -methyl- d -aspartate receptor inhibition.
Finally, STN or GPi DBS may be used to smooth out motor fluctuations and reduce dyskinesias.
Levodopa Induced Dyskinesias
| Pattern | Phenomenon | Management |
|---|---|---|
| Peak dose (I–D–I) | Chorea | Reduce each dose of levodopa |
| Add dopamine agonists | ||
| Dystonia | Reduce each dose of levodopa | |
| Clonazepam | ||
| Baclofen | ||
| Anticholinergics | ||
| Pharyngeal dystonia | Reduce each dose of levodopa | |
| Add anticholinergics | ||
| Respiratory dyskinesia | Reduce each dose of levodopa | |
| Add dopamine agonists | ||
| Myoclonus | Clonazepam | |
| Akathisia ∗ | Anxiolytics | |
| Propranolol | ||
| Opioids | ||
| Diphasic (D–I–D) | Dystonia | Increase each dose of levodopa |
| Baclofen | ||
| Sinemet CR | ||
| Stereotypies | Increase each dose of levodopa | |
| Baclofen | ||
| Off dyskinesia | Dystonia | Baclofen |
| Dopamine agonists | ||
| Anticholinergics | ||
| Sinemet CR | ||
| Tricyclics | ||
| Botulinum toxin | ||
| Akathisia ∗ | Anxiolytics | |
| Propranolol | ||
| Opioids | ||
| Striatal posture ∗ | Dystonia | Increase levodopa |
| Anticholinergics | ||
| Thalamotomy | ||
| Botulinum toxin |
I–D–I , Improvement–dyskinesia–improvement; D–I–D , dyskinesia–improvement–dyskinesia.
∗ May be unrelated to levodopa therapy.
Sources
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