Temporary Alternative Routes for Administering Duodopa When PEG Tube is Blocked
When a PEG tube is blocked in a patient receiving Duodopa (levodopa-carbidopa) gel, a nasojejunal tube should be used as the temporary alternative route until the PEG tube can be replaced or unblocked. 1, 2
Immediate Management Options
- For mature stoma tracts (>4 weeks old), direct replacement through the existing tract should be attempted before the tract closes completely 1
- A balloon-tipped Foley catheter of the same size can be used temporarily to keep the tract open if no commercially available gastrostomy tube is available for immediate replacement 1
- This temporary solution allows for continued administration of Duodopa until proper replacement can be performed 1
Nasojejunal Tube as Primary Alternative
- Nasojejunal tube placement is the preferred temporary alternative for short-term delivery of Duodopa when the PEG tube is blocked 2
- Nasojejunal tubes can be effectively used for periods up to 4-6 weeks, making them suitable temporary alternatives 2
- The nasojejunal route allows for direct delivery of medication to the jejunum, which is essential for proper absorption of Duodopa 3, 4
Verification of Tube Placement
- After placement of a nasojejunal tube, proper positioning must be confirmed before use 1
- Verification methods include:
Considerations for Duodopa Administration
- Continuous delivery of levodopa-carbidopa to the jejunum is essential for reducing motor fluctuations in advanced Parkinson's disease 3, 4
- The nasojejunal route maintains the direct delivery to the small intestine, preserving the pharmacokinetic advantages of continuous intestinal infusion 5
- Proper dosing adjustments may be needed when switching from PEG-J to nasojejunal administration 5
Prevention of Future Blockages
- Routine water flushing after medication administration can prevent tube occlusion 1
- Simple water flushing should be the first attempt to regain patency if the tube becomes clogged 1
- For persistent obstruction, a guide wire or commercially available tube declogger can be used by an expert 1
Cautions and Contraindications
- Avoid using cola-containing carbonated drinks or pancreatic enzymes to unclog tubes due to risk of bacterial contamination 1
- The use of 8.4% w/v sodium bicarbonate solution to unblock tubes is not evidence-based 1
- Home-made blenderized admixtures should not be utilized as they are less safe and effective than commercial formulations 1
Long-term Solutions
- If the PEG tube cannot be unblocked or replaced, arrangements should be made for placement of a new PEG-J tube 6
- For long-term administration (>6 weeks), PEG or PEJ is the preferred access device 2
- Percutaneous radiological gastrostomy (PRG) can be used as an alternative technique if endoscopic tube placement cannot be performed 1, 7