What are the treatment recommendations for a patient with Parkinsonism experiencing pro facial dyskinesia?

Treatment of Orofacial Dyskinesia in Parkinsonism

The primary treatment for orofacial dyskinesia in a patient with Parkinsonism is to reduce the levodopa dose, as dyskinesias are directly caused by excessive dopaminergic stimulation. 1, 2

Critical First Step: Distinguish the Type of Dyskinesia

Before treating, you must determine whether this is:

• Levodopa-induced dyskinesia (most common in Parkinson's disease): Choreiform movements affecting the orofacial region during "ON" periods when medication is working 3
• Tardive dyskinesia: Athetoid or choreic orofacial movements from chronic antipsychotic/dopamine-blocking drug exposure 3
• Paroxysmal kinesigenic dyskinesia: Brief episodes triggered by sudden movements, responds dramatically to carbamazepine 4

Treatment Algorithm for Levodopa-Induced Orofacial Dyskinesia

Step 1: Medication Adjustment (First-Line)

Reduce levodopa dosage incrementally - this is the most effective initial intervention for troublesome dyskinesias 1, 2. The FDA label for dopamine agonists explicitly states that "decreasing the dose of dopaminergic medications may ameliorate this adverse reaction" 2.

• Monitor for worsening of parkinsonian symptoms during dose reduction 1
• Consider protein redistribution diet (low-protein breakfast/lunch, normal protein at dinner) to optimize levodopa absorption and potentially allow lower doses 3, 1, 5
• Ensure levodopa is taken 30 minutes before meals to maximize efficacy at lower doses 3, 1, 5

Step 2: Add Amantadine (If Dose Reduction Insufficient)

Amantadine is the only pharmacologic agent with evidence for suppressing established dyskinesia 6. It provides mild dopaminergic effects while paradoxically reducing dyskinesia intensity 3.

Step 3: Advanced Therapies (For Refractory Cases)

Deep brain stimulation (DBS) is highly effective when dyskinesias remain troublesome despite medication optimization 4, 1:

• Target globus pallidus internus (GPi) when the primary goal is reducing "ON" medication dyskinesias without further medication reduction 4, 1
• GPi DBS is preferred over subthalamic nucleus (STN) DBS for patients with cognitive or depression concerns 1
• STN DBS is appropriate when the goal is to reduce dopaminergic medications significantly, which secondarily improves dyskinesias 4

Treatment Algorithm for Tardive Dyskinesia

Discontinue the causative dopamine-blocking medication immediately - this is the only specific treatment 3:

• If discontinuation would precipitate psychiatric relapse in a patient in full remission, continue current dose only under these specific circumstances 3
• Otherwise, attempt to lower the dose or switch to an atypical antipsychotic with lower extrapyramidal side effect profile 3
• Monitor with Abnormal Involuntary Movement Scale every 3-6 months 3

Critical caveat: Tardive dyskinesia may persist or worsen even after stopping the offending medication, unlike withdrawal dyskinesias which almost always resolve 3.

Common Pitfalls to Avoid

• Do not increase levodopa dose in response to orofacial dyskinesia - this will worsen the movements 1, 2
• Do not confuse dyskinesia with parkinsonian tremor - dyskinesia occurs during "ON" periods with good medication effect, while tremor worsens during "OFF" periods 7
• Do not use strict low-protein diets - these lack evidence and risk malnutrition; use protein redistribution instead 3, 1
• Monitor for withdrawal symptoms (insomnia, apathy, anxiety, depression, fatigue, sweating, pain) when reducing dopaminergic medications, as these do not respond to levodopa and may require temporary reinstitution of dopamine agonists 2
• Watch for protein redistribution complications: weight loss, micronutrient deficits, hunger before dinner, and paradoxically worsening dyskinesias requiring levodopa dose reduction 3, 1

Monitoring Requirements

• Assess body weight, vitamin B12, folate, and homocysteine levels regularly, especially with high or increasing levodopa doses 1, 5
• Monitor for gastrointestinal dysfunction (constipation, gastroparesis) that impairs levodopa bioavailability 1
• Evaluate for impulse control disorders (gambling, hypersexuality, compulsive spending/eating) with dopaminergic therapy 2