BackgroundBackground: 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 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 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 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.Deep brain stimulation (DBS), levodopa-carbidopa intestinal gel (LCIG) and subcutaneous apomorphine infusion (SCAI) are device-aided therapeutic options (DATs) for intractable motor complications in advanced Parkinson's disease (PD). 1,2 Their longterm efficacy can be compromised by the recurrence of motor and non-motor fluctuations, as well as by the emergence of complications or non-responsive symptoms. [3][4][5][6][7] Studies addressing the combined effect of the above therapies are limited. We report a series of patients from the Cretan PD Registry who required 2 such therapies for the optimal management of their symptoms.Since 2009, all patients diagnosed with PD at the University Hospital of Heraklion in Crete (UHHC, a tertiary referral center for South East Greece) according to the United Kingdom (UK) PD Society Brain Bank Criteria are entered onto the Cretan PD Registry. This registry includes wellcharacterized PD patients, who are followed regularly along the course of their disease and was initially established with the aim of identifying the distinct phenotypic characteristics of familial PD in the isolated population of Crete. All advanced PD patients who were simultaneously on 2 active DATs from January 2009 to August 2020 were studied. Patients that switched from 1 therapy to another were not included. Indications for dual therapy, outcomes, and side-effects of these combinations are reported.
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