Could DBS become ineffective at high dopamine levels?

[Anonymous]

Dear Dr. Okun:

Thank you for your recent posts on statistical studies on many PD DBS cases at your and other centers. Would your programming experts happen to have run into the following situation I seem to see in my family member with DBS biSTN over 10 years ago:

Could a high enough level of daily dopamine (>2000 mg / day) essentially overwhelm or mask the effect of the electrical stimulation ? Could there exists a dopamine level at which the patient no longer recognizes just the effect of a stimulation change?
I thought that for most PD patients DBS is meant to play the major role, with medication adding a fine-tuning function.
How does one recognize "overkill" in the total treatment?
And if it is no longer practical to restart the patient slowly from zero meds and zero stim (very severe dystonic pain, or fluctuating response to large changes), is there a strategy to re-discover the therapeutic window by slowly reducing meds and / or stim from above?

Thank you.

[Dr. Okun]

It is all empirical trial and error and in brittle cases of PD one must make changes over time. Interestingly in most cases stim parameter changes are few; however med changes may be many.

In many cases DBS patients with good outcomes stop feeling ons and off's and this is bothersome to some patients although it is usually a sign of success.
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Michael S. Okun, M.D.