Management of Levodopa‑Induced Dyskinesia in Parkinson’s Disease

Deep Brain Stimulation (DBS)

DBS is the most effective therapy for levodopa‑induced dyskinesia when optimized oral treatment is no longer sufficient. The recommendation is based on clinical practice data from the Movement Disorder Society. 1
Subthalamic nucleus DBS (STN‑DBS) yields large improvements in motor fluctuations, dyskinesia, and overall motor function, with benefits persisting for more than 15 years. Evidence comes from long‑term cohort studies. [1][2]
Globus pallidus internus DBS (GPi‑DBS) is equally effective as STN‑DBS for dyskinesia control in a 3‑year comparative trial. This reflects moderate‑quality comparative evidence. [1][2]
Key distinction: STN‑DBS typically permits a reduction in levodopa dosage (which can further lessen dyskinesia), whereas GPi‑DBS does not produce a comparable dose‑saving effect. [1][2]
Adverse‑event profile of DBS includes surgical or hardware complications, neuropsychiatric symptoms, dysarthria, and gait disturbances. These are reported in safety analyses of DBS registries. 2

Levodopa‑carbidopa intestinal gel (LCIG) provides a moderate increase in “on‑time without troublesome dyskinesia” and a moderate reduction in daily off‑time, with benefits lasting 2–3 years. Data derive from prospective open‑label studies. [1][2]
Continuous subcutaneous apomorphine infusion (CSAI) produces a moderate improvement in on‑time and off‑time durations, with effects maintained for at least 2 years. Evidence is based on controlled observational cohorts. 2

Early referral for advanced‑therapy evaluation (DBS or continuous infusion) is recommended once oral therapy has been optimized, rather than waiting for severe disability to develop. This recommendation follows expert consensus within the Movement Disorder Society. 2
Algorithm for diphasic dyskinesia: After attempting levodopa fractionation, patients who remain symptomatic should be referred for DBS assessment. 2
When oral therapy fails: Patients should be referred for evaluation of DBS (either STN or GPi) or for continuous infusion options. 2
Choosing between STN‑DBS and GPi‑DBS: If reduction of levodopa dose is a therapeutic goal, STN‑DBS is preferred; otherwise, both targets are considered equally effective for dyskinesia control. 2