Parkinson's Disease: Acute management of patients with Parkinson's disease who cannot take their usual medications, due to compromised swallow or nil by mouth status

Publication: 27/02/2015  --
Last review: 22/02/2018  
Next review: 01/02/2021  
Clinical Guideline
CURRENT 
ID: 4120 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Acute management of patients with Parkinson’s disease who cannot take their usual medications, due to compromised swallow or nil by mouth status.

  1. Introduction
  2. Neuroleptic malignant syndrome
  3. Drugs that should be avoided in Parkinson’s disease
  4. Converting existing Parkinson’s disease medicines to allow administration to patients who are dysphagic or have an enteral tube.
  5. Converting existing Parkinson’s disease medicines to an equivalent topical rotigotine preparation.
  6. Summary of drug conversions.

1. Introduction

Parkinson’s disease (PD) is a complex neurological condition. PD drugs generally work by increasing dopaminergic stimulation in the brain. It is crucial that they are not omitted or delayed or else there will be a sudden drop in dopaminergic stimulation. This results in patients developing extremely distressing symptoms such as pain, muscle stiffness, difficulty walking, falls and dysphagia and the risk of life-threatening complications such as neuroleptic malignant syndrome.

The reasons patients with Parkinson’s disease are admitted to hospital may not be directly related to their condition. However if they are not able to take their medications as required to maintain mobility, swallowing and activities of daily living the symptoms of their Parkinson’s disease will rapidly deteriorate. This will make them more dependent and they will have a higher risk of aspiration and falls. If patients with Parkinson’s disease are not managed appropriately on admission this can lead to life-threatening complications, delayed recovery, delayed discharge and poor outcomes.

As health care professionals we all have a duty of care to manage patients with Parkinson’s disease correctly. These guidelines will help you safely manage patients with Parkinson’s disease who cannot take their usual medications due to impaired swallow or “nil by mouth” (NBM) status during their acute admission.

 KEY POINTS

  • Patients with Parkinson’s disease must receive their medications on time
  • Oral drugs may be converted to a patch or dispersible preparation
  • Do not omit Parkinson’s disease drugs due to impaired swallow or NBM status

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2. Neuroleptic malignant syndrome

A rare but potentially fatal syndrome called “neuroleptic malignant syndrome” may occur in patients with Parkinson’s disease if Parkinson’s drugs are omitted.

Or

There is a dramatic dose reduction of medications used for Parkinson’s disease.

Or

Dopamine receptor blocking drugs (see below) are prescribed.

The signs of neuroleptic malignant syndrome are summarized by the acronym “FALTER”:

F=FEVER

A=AUTONOMIC INSTABILITY (i.e. erratic changes in blood pressure, pulse and sweating).

L=LEUCOCYTOSIS (i.e. high white cell count).

T=TREMOR.

E=ELEVATED ENZYMES (i.e. high creatine kinase).

R=RIGIDITY OF MUSCLES (i.e. limbs feel very stiff when you try to move them).

Neuroleptic malignant syndrome is a medical emergency and may rapidly lead to renal failure, cardiac arrest and death. It requires prompt treatment with IV fluids, drugs to rapidly increase the dopamine levels and careful monitoring in a high dependency unit.

In order to avoid neuroleptic malignant syndrome in patients with Parkinson’s disease we recommend the following:

  • Allow patients to self-medicate if possible as per hospital policy.
  • Use the patient’s own medication rather than waiting for pharmacy stock, labelled compliance aids can be used.
  • Contact the on-call pharmacist for advice
  • Parkinson’s disease drugs are available in the emergency drug cupboard.
  • Write up Parkinson’s disease drugs immediately to avoid delayed doses.
  • Escalate to a senior doctor if the patient is unable to swallow or nil by mouth.
  • If a naso-gastric tube is required insert as soon as possible.
  • If possible put Parkinson’s disease patients first on any surgical lists in order to avoid prolonged periods without their medications.
  • At pre-assessment liaise with appropriate specialist health care professional for Parkinson’s disease medication regimen.
  • Parkinson’s disease medications must not be discontinued during the pre, post and if possible the peri-operative period.
  • Speech and language assessment if there any concerns regarding safety of patient’s swallow and ability to take oral medication rather than via enteral tube.

KEY POINT:

  • If you are unable to administer medicines to a patient with Parkinson’s

Take action now

  • For help in-hours contact Parkinson’s specialist Nurses ext. 26689
  • Speech and Language Therapy cross site bleep 5044
  • Ward Pharmacist.

 

  • For help out of hours contact:
  • Pharmacist ext. 65168
  • after 19:30 pharmacy bleep 1247
  • Neurology registrar via switchboard

 

KEY POINT:

  • If you need further advice about how to manage a patient with Parkinson’s disease, contact the Neurology registrar on call via:
  • Faxed referral 0113 39 22244
  • Hospital switchboard for urgent queries (available 24 hours a day 7 days a week).

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3. Commonly used drugs that should be avoided in patients with Parkinson’s disease.

The drugs in the left hand column may worsen the symptoms of Parkinson’s disease and increase the risk of neuroleptic malignant syndrome because they block dopamine receptors. The drugs in the right hand column are safer alternatives.

Avoid these drugs

Consider using these drugs instead

Anti-emetics

Anti-emetics

Phenothiazines e.g. prochlorperazine and chlorpromazine.
Anti-psychotic related anti-emetic e.g. haloperidol and levomepromazine.
Metoclopramide
Cinnarizine
Nabilone
Hyoscine
Hydrobromide
Cyclizine

Domperidone (please note MHRA advice risk of prolonged QT).
https://www.gov.uk/drug-safety-update/domperidone-risks-of-cardiac-side-effects

Ondanestron (MHRA advice risk of prolonged QT).
https://www.gov.uk/drug-safety-update/ondansetron-for-intravenous-use-dose-dependent-qt-interval-prolongation

(Do not use ondanestron with apomorphine).
Dexamethasone

Anti-psychotics

Anti-psychotics

Amisulpiride
Chlorpromazine
Fluphenazine
Haloperidol

Lorazepam and diazepam (agents of choice).
Sertraline
Quetiapine
Mirtazapine use on advice from neurology.

This is not an exhaustive list. Please refer to BNF, LTHT formulary, medicines information, pharmacy or neurology.

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4. Conversion table for switching Parkinson’s disease oral levodopa medications to a dispersible levodopa preparation to co-beneldopa (Madopar) dispersible.

Levodopa is the most powerful oral medication used in Parkinson’s disease and should not be omitted. If the patient cannot swallow tablets but can manage fluids (including thickened fluids), or has an enteral tube in situ convert the levodopa tablets/capsules to co-beneldopa (Madopar) dispersible using the table below. Alternatively an equivalent levodopa dose may be administered via a rotigotine transdermal patch (see section 6).

4.1 Conversion Table

Current

Equivalent

Madopar (co-beneldopa) 12.5/50mg capsule

Madopar (co-beneldopa) 12.5/50mg dispersible tablet

Madopar (co-beneldopa) 25/100mg capsule

Madopar (co-beneldopa) 25/100mg dispersible tablet

Madopar (co-beneldopa) 50/200mg capsule

Two Madopar (co-beneldopa) 25/100mg dispersible tablets

Madopar (co-beneldopa) Controlled Release 25/100mg capsule.

Madopar (co-beneldopa) 25/100mg dispersible tablet.
Seek advice from pharmacy as dose interval may need adjusting.

Sinemet (co-careldopa) 12.5/50mg tablet

Madopar (co-beneldopa) 12.5/50mg dispersible tablet

Sinemet (co-careldopa) 10/100mg tablet

Madopar (co-beneldopa) 25/100mg dispersible tablet

Sinemet-plus (co-careldopa) 25/100mg tablet

Madopar (co-beneldopa) 25/100mg dispersible tablet

Sinemet-275 (co-careldopa) 25/250mg tablet

Two Madopar (co-beneldopa) 25/100mg dispersible tablets and One Madopar (co-beneldopa) 12.5/50mg dispersible tablet.

Half-sinemet Controlled Release 25/100mg tablet

Madopar (co-beneldopa) 25/100mg dispersible tablet.
Seek advice from pharmacy as dose interval may need adjusting.

Sinemet Controlled Release 50/200mg tablet

Two Madopar (co-beneldopa) 25/100mg dispersible tablets.
Seek advice from pharmacy as dose interval may need adjusting.

Entacapone 200mg tablet

Tablets disintegrate when shaken with at least 10mls of water. This dispersion must be administered immediately and care must be taken to avoid staining skin and clothing.

Stalevo/Stanek/Sastravi

(levodopa, carbidopa, entacapone) preparations

 

Tablets can be crushed and dispersed in 15mls of water. This dispersion must be administered immediately and care must be taken to avoid staining skin and clothing.
Seek advice from pharmacy if converting from Stalevo/Stanek/Sastravi to constituents.

In practice the neurology team routinely use a 1:1 conversion for both immediate release and controlled release preparations of co-careldopa (Sinemet), co-beneldopa (Madopar) to co-beneldopa (Madopar) dispersible tablets.

4.2 Continuous jejunal levodopa therapy (Duodopa) should be maintained. These patients are at very high risk of neuroleptic malignant syndrome if Duodopa is stopped without appropriate dopaminergic replacement. Contact PD nurse ext. 26689, Pharmacy or Healthcare at Home nurse helpline for advice 0800 458 4410

4.3 How to continue with current oral dopamine agonist medications via an enteral tube or crushed in unthickened or thickened fluids.

Dopamine agonist

Advice

Pramipexole immediate release

Crush and disperse each dose in 15mls of water

Pramipexole prolonged release

Convert to an equivalent daily dose of immediate release pramipexole then split this into three doses per day and crush and disperse each dose in 15mls of water.

Ropinirole immediate release

No need to crush they will disperse in 15mls of water.

Ropinirole prolonged release

Convert to an equivalent daily dose of immediate release ropinirole then split into three doses per day and disperse each dose in to 15mls of water.

4.4 How to continue with current topical/transdermal patch and sub-cutaneous dopamine agonist medications.

Dopamine agonist

Advice

Rotigotine (Neupro) transdermal patch

Continue

Apomorphine (Apo-go) sub-cutaneous infusion

Continue.
Do not stop or alter pump settings.
Pump set up video available on LTHT intranet Parkinson’s intranet page

http://lthweb.leedsth.nhs.uk/sites/parkinson2019s-information/

Written set up instructions, flow rate charts, prescription charts and error codes can be found on Leeds net formulary.

Contacts for further information:

-Parkinson’s disease clinical nurse specialists: ext. 26689
-Ward L17 neurology ext. 27417
-Apo-go 24 hour technical helpline 0844 880 1327

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5. Conversion tables for switching patients Parkinson’s disease oral medications to a transdermal rotigotine patch preparation.

Indication: If a patient with Parkinson’s disease is nil by mouth, nil by enteral tube or likely to have problems absorbing drugs via the gastrointestinal tract.

5.1 Converting co-beneldopa (Madopar) and co-careldopa (Sinemet) to a rotigotine patch.

The conversion rate is 1mg of oral levodopa is approximately 0.033mg rotigotine.

To convert co-beneldopa (Madopar) capsules or co-careldopa (Sinemet) tablets to a rotigotine patch:

(i) Add up all the levodopa doses (circled below) given in a 24 hour period.

(ii) Multiply this “total 24 hour levodopa dose” number by 0.033 to calculate the equivalent rotigotine patch dose.

(iii) Give the nearest patch dose of rotigotine.

Further examples of commonly used co-beneldopa (Madopar) and co-careldopa (Sinemet) regimens: OD=once a day, BD=twice a day, TDS= three times a day, QDS=four times a day.

Current co-beneldopa (Madopar) or co-careldopa (Sinemet) oral drug regimen.

Daily levodopa dose

Rotigotine patch equivalent

12.5/50mg BD

100mg

4mg/24 hours

12.5/50mg TDS

150mg

6mg/24hours

12.5/50mg QDS

200mg

6mg/24hours

25/100mg TDS

300mg

10mg/24 hours

25mg/100mg QDS

400mg

12mg/24 hours

25mg/100mg TDS and 12.5/50mg TDS

450mg

14mg/24 hours

25mg/100mg QDS and 12.5/50mg QDS

600mg

16mg/24 hours *

50mg/200mg TDS

600mg

16mg/24 hours *

50mg/200mg QDS

800mg

16mg/24 hours *

Rotigotine patches are available in 1mg, 2mg, 3mg, 4mg, 6mg and 8mg/24 hour doses. 1mg and 3mg are only licensed for use in restless legs syndrome. The maximum licensed dose of rotigotine is 16mg/24 hours. Do not cut patches to achieve the correct dose and they do not need to be stored in the fridge.

*Administer 16mg/24 hours rotigotine transdermal patch and also contact Parkinson’s team/neurology SPR on call for advice, as calculated dose >16mg licensed dose

5.2 Converting levodopa/carbidopa/entacapone (Stalevo/Stanek/Sastravi) to a rotigotine patch

The conversion rate of 1mg levodopa in Stalevo/Stanek/Sastravi is approximately 0.04mg rotigotine*

To convert levodopa/carbidopa/entacapone tablets to a rotigotine patch:

(i) Add up the levodopa component (circled in the example below) of the doses given in a 24 hour period.
(ii) Multiply this “total 24 hour Stalevo/Stanek/Sastravi dose” number by 0.04 to calculate the equivalent rotigotine patch dose.
(iii) Use the nearest patch dose of rotigotine.
(iv)

If the total daily levodopa dose is over 1000mg, the patient may need a higher dose of rotigotine than the maximum licensed dose of 16mg/24 hours (or sub-cutaneous apomorphine infusion may be needed instead) and you should contact the neurology registrar on call for advice.

Further examples of commonly used levodopa/carbidopa/entacapone regimens

Current Stalevo/Stanek/Sastravi regimen

Daily levodopa dose

rotigotine equivalent mg/24hours (maximum dose 16mg/24hrs)

50mg/12.5mg/200mg TDS

150mg

6mg

75mg/18.75mg/200mg TDS

225mg

10mg

100mg/25mg/200mg TDS

300mg

12mg

125mg/31.25mg/200mg TDS

375mg

16mg

150mg/37.5mg/200mg TDS

450mg

16mg *

175mg/43.75mg/200mg TDS

525mg

16mg *

200mg/50mg/200mg TDS

600mg

16mg *

*Administer 16mg/24 hours rotigotine transdermal patch and also contact Parkinson’s team/neurology SPR on call for advice, as calculated dose >16mg licensed dose.

5.3. Converting oral dopamine agonists to a rotigotine patch

  • 1mg pramipexole salt is equivalent to approximately 3.3mg rotigotine.
  • 1mg ropinirole is equivalent to approximately 0.66mg rotigotine.

Pramipexoleimmediate release (salt)

Pramipexoleprolonged release (salt)

Equivalent rotigotine patch dose

Ropiniroleimmediate release

Ropiniroleprolonged release

Equivalent rotigotine patch dose

0.125mg TDS

0.375mg OD

2mg/24 hours

0.25mg TDS

2mg OD

2mg/24 hours

0.25mg TDS

0.75mg OD

4mg/24 hours

1mg TDS

4mg OD

4mg/24 hours

0.5mg TDS

1.5mg OD

6mg/24hours

2mg TDS

6mg OD

4mg/24 hours

0.75mg TDS

1.5mg+0.75mg OD

8mg/24hours

3mg TDS

8mg OD

6mg/24 hours

1mg TDS

3mg OD

10mg/24hours

4mg TDS

12mg OD

8mg/24 hours

1.25mg TDS

3mg + 0.75mg OD

12mg/24hours

6mg TDS

18mg OD

12mg/24hours

1.5mg TDS

4.5mg OD

16mg/24hours

8mg TDS

24mg OD

16mg/24 hours

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6. Summary of conversion rates for Parkinson’s disease drugs:

Rotigotine 3.3mg is equivalent to
- Levodopa 100mg
- Levodopa/carbidopa/entacapone 75/18.75/200mg
- Ropinirole 5mg
- Pramipexole salt 1mg

 

To convert each oral drug prescription to an equivalent rotigotine patch dose:

(i) Add up all the doses of one particular oral drug over 24 hours.

(ii) Multiply the 24 hour total dose (in mg) of this drug as follows:
levodopa (co-beneldopa/ Madopar and co-careldopa/Sinemet x 0.033
Stalevo/Stanek/Sastravi x 0.04
Ropinirole x 0.66
Pramipexole x 3.3

(iii) Choose the nearest rotigotine patch dose up to a maximum of 16mg/24 hours.

The following Parkinson’s disease drugs can be omitted relatively safely but you should seek Pharmacy advice within 48 hours: rasagiline (Azilect), selegiline (Zelapar, Eldepryl), safinamide (Xadago), amantadine (Symmetrel), entacapone (Comtess), opicapone (Ongentys) and tolcapone (Tasmar).

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Provenance

Record: 4120
Objective:
Clinical condition:

Parkinson's Disease

Target patient group: Patients with Parkinson's disease who cannot take their usual medications, due to compromised swallow or nil by mouth status
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

Drug conversion rates based on:
Tomlinson CL, Stowe R, Patel S, Rick C, Gray R, Clarke C.
Systematic review of levodopa dose equivalency reporting in Parkinson’s disease.
Movement Disorders Vol 25 No 15, 2010. P 2649-2653.

Medicines administration references:
White R et al. Handbook of drug administration via enteral feeding tubes; 2007.
Smyth J et al. The NEWT guidelines for administration of medication to patients with enteral feeding tubes or swallowing difficulties; 2010.

What to do when people with Parkinson's disease cannot take their usual oral medications:
Alty J, Robson J, Duggan-Carter P, Jamieson S.
Pract Neurol. 2016 Apr;16(2):122-8. doi: 10.1136/practneurol-2015-001267.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

This guideline will be audited across the trust within the first 12 months, revision date 12 months from publication.

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