Treatment pathway for Levodopa Carbidopa Intestinal Gel (LCIC)Knowledge
Levodopa carbidopa intestinal gel (LCIG) bypasses the stomach and avoids the effects of delayed or slow gastric emptying. It introduces stable levodopa concentration and can give increased daily 'on' time without increased dyskinesia, while reducing 'off' time.
The newly updated Parkinson's non-oral pathway has a treatment pathway devoted to LCIG (fig 1) and provides a thorough overview of the best clinical practice and patient flow, with the patient journey documented through several pathways.
Figure 1: LCIG pathway overview
The first pathway establishes patients' suitability whilst the second pathway outlines inclusion and exclusion criteria for treatment and lists the reasons for the referral process.
The next pathway level is the specialist overview pathway (fig 2) which details preparation for the procedure, the procedure itself, and the aftercare required. This links into ongoing care once the treatment is initiated, including that of self-management and the role of the community team.
Figure 2: LCIG specialist pathway
Preparation for LCIG is an essential element of the treatment, both in terms of presenting a clear picture of the procedure to the patient, and understanding their experiences of Parkinson's. It is also important to ensure the patient understands what management will entail following the procedure.
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Screening for eligibility and suitability can take place up to six weeks before the procedure, and it is extensive.
In addition to routine investigations, vitamin B12 levels and weight, the individual is asked to keep an 'on/off' diary, required to be assessed with:
The Parkinson's disease questionnaire (PDQ 39)
Non-Motor Symptoms Scale (NMSS)
Montreal Cognitive Assessment (MOCA)
Hospital anxiety and depression scale (HADS)
The Unified Parkinson's Disease Rating Scale (UPDRS)
Taken from the Parkinson's Tailored Management course
Module 1, Medication / Session 5: LCIG
Louise Ebenezer, Parkinson's specialist nurse discusses the importance of 'assembling your kit' - the various equipment and elements required to successfully use the LCIG treatment. In this 2 minute video, taken from the Parkinson's Tailored Management Course (session 5 of module 1), Louise discusses what the 'kit' comprises, the importance of a nurse's role in ensuring the kit is in the right place at the right time and in supporting the patient, and explains the 'sliding scale' of medication use in LCIG.
Ensuring that a full 'kit' is prepared in advance of the procedure taking place and that the individual with Parkinson's is aware of each element and how it will be used is very important. Up to 5 days' worth of the LCIG medication can be provided by the pharmacist at a time, and this will include NG, PEJ, pump bag, syringes, and LCIG cassettes.
Ensuring that patients are fully aware of the aftercare and elements of self-management to include in their daily living following treatment is also very important. A common complication of LCIG is Buried Bumper Syndrome and this can be avoided through good patient education and appropriate monitoring and management by healthcare professionals.
The final element of the LCIG pathway therefore addresses all aspects of ongoing care and review, highlighting what the patient should be monitoring, routine annual reviews, and reviews in emergency situations (fig 3).
Figure 3: LCIG specialist pathway: review
The impact of LCIG on people with Parkinson's can be immensely positive, with the treatment having been found to lead to sustained improvements in motor fluctuations, non-motor symptoms particularly sleep and fatigue, mood and cognition and gastrointestinal domains, as well as quality of life in advanced Parkinson's patients (Antonini 2017, Pålhagen 2016).
The Parkinson’s disease non-oral treatment pathway has been supported through a financial grant from AbbVie Ltd and financially supported by Britannia Pharmaceuticals Ltd and Merz Therapeutics UK. Whilst the sponsors have reviewed the content of the pathway for medical and factual accuracy, they have had no further input in the educational content of this activity.
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