Management of Parkinson’s Disease in Primary and Secondary Care for patients with
compromised swallow or those patients deemed Nil By Mouth.
To aid the management and treatment of Parkinson’s patients with
compromised swallow and those nil by mouth.
AUTHORS:
Alison Waldron (Acute Clinical Nurse Specialist in Parkinson’s disease)
Steven Shanu (Resident Pharmacist)
Sarah Baig (Medicines Information/Neurology Directorate Pharmacist)
Dr Janine Barnes (Neurology Specialist Pharmacist)
Dr Shams Duja (Consultant in Elderly Care)
Dr Alistair Lewthwaite (Consultant Neurologist)
Trudy Gaskin (Parkinson’s disease Nurse Specialist – community based)
VERSION CONTROL
June 2014
August 2014
December 2014
1.0
Consultation with Dr Martin GP
and Dr Bowen Palliative Care
Consultant
This is a new document
Consultation with consultants in
secondary care Review of document – version 1.1
Dr Michael
Dr Stellman
Dr McGrath
Dr Ijaola
Dr Lewthwaite
Dr Douglas
Version 1.1
Circulated to GP’s
PBP’s
DGNHSFT Consultants
DGNHSFT Nurses
Dudley CCG
Dudley MBC
NOC
Project Support
CCG Head of Commissioning
1
A translation service is available for this document. The Interpretation/Translation Policy,
Guidance for Staff is located on the intranet under Trust-wide Policies.
Section
1
2
3
4
5
6
7.0
7.1a)
7.1b)
7.2 a)
8.0
9.0
10.0
11.0
12.0
13.0
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Contents
Page
Number
Introduction
Statement of Intent
Scope
Definitions
Duties & Responsibilities
Consequences of missing Parkinson’s medicines
Parkinson’s disease management in patients – secondary
care
Patients with a compromised swallow or nil by mouth in
secondary care
Hospital – Surgery/NG patients (flow chart)
3
3
3
3
3
4
4
Patients with a compromised swallow or Nil by Mouth in
primary care
Nasogastric administration of Levodopa and Dopamine
agonist
Conversion table for transdermal delivery
Drugs to avoid in Parkinson’s disease
Apomorphine guidelines
Contact details
References and acknowledgements
Common oral medicines used in Parkinson’s disease
Commonly used drugs to avoid in Parkinson’s disease
Conversion algorithm
Conversion charts
Review and monitoring adherence to guideline
4
5
5-6
6-7
8
8
8
9
9
10
11
12
13
14
2
1.
INTRODUCTION
Clinical experience and audit has revealed that Parkinson’s patients who are nil by mouth
(NBM) or experience swallowing difficulties are experiencing lack of consistency in their
prescribing of medication. This guideline aims to standardise treatment with respect to
appropriate timings, doses and formulations for patients.
2.
STATEMENT OF INTENT
This document is designed to rationalise the prescribing in this patient group.
3.
SCOPE
The Parkinson’s disease Specialist Nurses are responsible for the day to day management
of Parkinson’s disease patients both in hospital and in the community.
The Pharmacists are responsible for specialist advice on specific medicines management
and appropriate use of dose calculators.
The consultant lead and medical team is responsible for the day to day medical
management of Parkinson’s disease
The Area Clinical Effectiveness Committee will oversee the ratification of the guideline and
appropriate review.
4.
DEFINITIONS
CK
MAO-B
NBM
NG
NMS
Pd
L-Dopa
COMT
CR
5.
Creatinine Kinase
Monoamine oxidase B inhibitor
Nil by mouth
Nasogastric
Neuroleptic Malignant Syndrome
Parkinson’s disease
Levodopa
Catechol-o-methyl transferase
Controlled release
DUTIES & RESPONSIBILITIES
For patients managed in primary care please contact Trudy Gaskin (Parkinson’s disease
Nurse Specialist) or Dr Janine Barnes (Neurology Specialist Pharmacist).
For secondary care patients please contact Alison Waldron (Acute Clinical Nurse Specialist in
Parkinson’s disease), Dr Shams Duja (Consultant in Elderly Care) or Dr Alistair Lewthwaite
(Consultant Neurologist).
Review and update of this guideline will take place every 3 years.
3
6.
CONSEQUENCES OF MISSING PARKINSON’S DISEASE DRUGS
Medication is crucial in optimal management of Parkinson’s disease. If medication is not given
it can result in the deterioration in patients’ symptoms, including reduced swallow, risk of
aspiration, speech problems, increased risk of falls and increased dependence on nursing
staff. At worst it may develop into Neuroleptic Malignant Syndrome.
Neuroleptic Malignant Syndrome






Rare
Due to sudden withdrawal of PD medication
Hyperthermia, muscle rigidity, altered level of
consciousness, autonomic instability and
elevated serum creatinine kinase (CK) level
Onset within 1 to 9 days
Major complications are respiratory, renal and
cardiovascular failure
Carries significant mortality
People with Parkinson’s disease are admitted to hospital for many reasons, very often
unrelated to their Parkinson’s. However if this is not managed appropriately on admission it
can lead to delayed recovery, delayed discharge and poor outcomes for patients and their
families.
7.0 PARKINSON’S DISEASE MANAGEMENT IN PATIENTS – SECONDARY CARE
7.1A) PATIENTS WITH A COMPROMISED SWALLOW OR NIL BY MOUTH IN
SECONDARY CARE
(Adapted from the NHS Tayside Administration of Medicine in the Peri-operative period)
Many people with Parkinson’s disease present to surgical specialties for the management of
conditions unrelated to their Parkinson’s. The decision to discontinue, or accidentally omit
medication pre-operatively can cause severe harm including inability to swallow, speak or
move increasing the risk of aspiration pneumonia, falls and fractures. It can precipitate an
acute withdrawal syndrome similar to Neuroleptic Malignant Syndrome which can be fatal.
If possible Levodopa treatment should be continued throughout the peri-operative period.
Selegiline and Rasagiline are both monoamine oxidase inhibitors (MAO-B) and can interact
with anaesthetic agents. The COMT inhibitors Entacapone, Tolcapone and Stalevo
(Entacapone plus Levodopa) can all interact with Adrenaline, Isoprenaline and
Noradrenaline. The anaesthetist should be informed.
If prolonged surgery expected or if oral route is going to be compromised post-operatively it
may be worthwhile converting a patient to Rotigotine transdermal patch pre-operatively.
Discuss with Parkinson’s nurse specialist/Neurology specialist pharmacist but in an
emergency the online conversion calculator can be used to switch to Rotigotine transdermal
patch. See online calculator
Note: bedside swallow test used by nurses on some wards is designed for stroke
patients only. Swallow problems are very common in Parkinson’s, particularly during
an intercurrent illness.
4
7.1 b) HOSPITAL FLOW CHART
If you think the patient’s swallow is compromised follow the following algorithm:
Contact Acute
Acute Clinical
Clinical Nurse
Nurse Specialist
Specialist for
for Parkinson’s
Parkinson’s disease
disease –– Bleep
Bleep 5026
5026
Contact
Refer to
to Speech
Speech and
and Language
Language therapy
therapy via
via Soarian
Soarian
Refer
If unable to contact Parkinson’s Disease Specialist Nurse
continue through flow chart
Hospital contact – Alison Waldron – Bleep 5026 (Acute Clinical Nurse Specialist in
Parkinson’s disease)
Can the patient tolerate a nasogastric (NG) tube?
YES
Follow NG administration
guidelines (section 8)
NO
Convert to Rotigotine patch
– see Hub
7.2 a) PATIENTS WITH A COMPROMISED SWALLOW OR NIL BY MOUTH IN
PRIMARY CARE
Due to the characteristics of Parkinson’s disease, patients may experience symptoms which
lead to changes in their ability to swallow safely. In turn this may lead to life threatening
conditions and reduced quality of life. It is therefore important to recognise and inform
patients and their families of the warning signs of a swallowing disorder in order to provide
early intervention and work with patients and their families in appropriate management and
advance care planning.
Early warning signs of a compromised swallow






Drooling
Coughing or choking on food and / or drink
Food sticking/pouching
Changes to speech
Frequent chest infections
Cognitive changes
Changes to a patients swallow may develop gradually or more quickly depending on the
cause. It is therefore necessary to assess patient’s individual circumstances and history to
determine the next appropriate actions.
5
A referral should be completed requesting an assessment from speech and language
therapists and dietician service. Advice should also be sought from Trudy Gaskin
(Parkinson’s disease Nurse Specialist) and / or Dr Janine Barnes (Neurology Specialist
Pharmacist). To access these professionals through the Dudley Rehabilitation Service a
combined referral form is available on the HUB, Dudley Group of Hospitals webpage or
telephone 01384 323145.
In some situations it may become necessary for a patient to be transferred to hospital for
nasogastric or percutaneous endoscopic gastrostomy.
Medication changes can be made by using this guidance and conversion charts below.
If a patient is recognised to be in the palliative / end of life care stages of Parkinson’s
disease please refer to the Palliative Care guidelines.
8. NASOGASTRIC ADMINISTRATION OF LEVODOPA AND DOPAMINE AGONIST
On occasions it may be necessary to administer Parkinson’s medications via an NG tube
temporarily although these recommendations can be followed for long term enteral
administration.
Normal prescription
Co-Beneldopa (Madopar)
Method of administration/alternative
Madopar dispersible, same doses as tablets.
CR formulations require a slight dose reduction.
12.5 mg Benserazide + 50 mg Levodopa.
25 mg Benserazide + 100 mg Levodopa.
Tablets disperse in 10 ml of water within 2 minutes
to give a cloudy white dispersion that flushes via an
8Fr NG tube without blockage
Co-Careldopa (Sinemet)
Standard formulations disperse in water
alternatively convert to equivalent dose of
dispersible Co-Beneldopa.
Tablets disperse readily when placed in 10 ml of
water to form a bright yellow dispersion that settles
quickly but flushes via an 8Fr NG tube without
blockage. Care must be taken to administer whole
dose owing to the tendency for settlement to the
bottom of the container/syringe.2
CR formulations require a slight dose reduction.1
6
Sinemet
(Co-Careldopa)
Madopar
(Co-Beneldopa)
Sinemet 62.5mg tablet
Madopar 62.5mg
dispersible tablet
Sinemet 110mg tablet
Madopar 125mg
dispersible tablet
Sinemet Plus 125mg
tablet
Madopar 125mg
dispersible tablet
Sinemet 275mg tablet
2 x Madopar 125mg
dispersible tablet
Half Sinemet CR
125mg tablet
Convert to ordinary
formulation dose
Sinemet CR 250mg
tablet
Convert to ordinary
formulation dose
Entacapone
Disperses less easily
Enteral tubes will need to be flushed well after use
Stalevo
(combination of Co-Beneldopa and Entacapone)
Give equivalent doses of Co-Beneldopa dispersible
as above and Entacapone as above.2
Rasagiline
Contacted the manufacturer, unfortunately no
information is available on crushing. Consider
switch to Selegiline if patient unable to swallow
Selegiline
Zelapar ( Melt (dissolves on the tongue)
1.25mg equivalent to 10mg Selegiline – If patient
able to take buccal tablets, alternatively crush
tablets. Syrup preparation 10mg/5ml (only for
enteral tubes)2
Amantadine
Liquid available (50mg/5ml) – for enteral tubes only
Amantadine hydrochloride is freely soluble in
water.2 The capsules may be opened and mixed
with water and administered immediately via an
enteral feeding tube.1,2
Ropinerole
Maintain same doses – Crush tablets. Tablets
disintegrate rapidly when placed in 10 mL of water
to give fine dispersion that flushes via an 8Fr NG
tube without blockage.1
Ropinerole XL
Convert to standard Ropinerole
Crush as above
7
Ropinirole
Controlled Release
Ropinirole (XL)
Starter pack
N/A
1mg tds
4mg/day
2mg tds
6mg/day
3mg tds
8mg/day
4mg tds
12mg/day
6mg tds
16mg/day
8mg tds
24mg/day
Pramipexole
Maintain same doses – crush tablets and disperse
in water2
Pramipexole PR (Prolonged Release)
Convert to standard Pramipexole
Crush as above
Pramipexole
(salt content)
Pramipexole
(base content)
0.125mg tds
0.088mg tds
0.25mg tds
0.18mg tds
0.5mg tds
0.35mg tds
0.75mg tds
0.53mg tds
1mg tds
0.7mg tds
1.25mg tds
0.88mg tds
1.5mg tds
1.05mg tds
9. CONVERSION TO TRANSDERMAL DELIVERY (PATCH SYSTEM) – VIA HUB
10. DRUGS TO AVOID IN PARKINSONS DISEASE
For drugs to avoid in Parkinson’s disease please refer to appendix 2
11.
APOMORPHINE PRESCRIBING/DISPENSING
Under no circumstances should this be initiated without involvement with a
Parkinson’s specialist.
11. a) HOSPITAL
If a patient is admitted on Apomorphine please contact the Parkinson’s disease Nurse
Specialist as soon as possible. If urgent advice is needed out of hours there is a
24 hour Apo-go helpline available on 0844 880 1327.
Out of hours please contact the on-call pharmacist via switchboard.
8
11. b) COMMUNITY
For any community queries regarding Apomorphine please contact Trudy Gaskin or
Dr Janine Barnes via Dudley Rehabilitation Service 01384 323145 or if urgent advice is
needed out of hours there is a 24 hour Apo-go helpline available on 0844 880 1327.
12.
CONTACT DETAILS
Alison Waldron (Acute Clinical Nurse Specialist in Parkinson’s disease), Dudley Group NHS
Foundation Trust. Bleep 5026
Trudy Gaskin (Parkinson’s Disease Nurse Specialist)
01384 323145 / 0792 070 2109
Dr Janine Barnes (Neurology Specialist Pharmacist)
01384 323145/ 0782 593 2587
13.
REFERENCES AND ACKNOWLEDGEMENTS
1. Smyth J, editor. The NEWT Guidelines for administration of medication to patients with
enteral feeding tubes or swallowing difficulties. Print version, 2nd edition published
2012. Online version updated more frequently, available at www.newtguidelines.com
(subscription required).
2. Handbook of Drug Administration via Enteral Feeding Tubes. Accessed via
www.medicinescomplete.com on 12th March 2013.
3. Cabergoline vs Pergolide vs Pramipexole vs Ropinirole. Grosset et al. Movement
Disorders2004;19 (11):1370-4
4. Ropinirole, Pramipexole, Cabergoline vs Rotigotine. Le Witt et al. Clinical
Neuropharmacology2007; 30 (5): 256- 65
5. Ropinirole vs Requip XL. Summary of product Characteristics, Requip XL. Electronic
Medicines Compendium.
6. Algorithm for estimating parenteral doses of drugs for Parkinson’s disease. Brennan
K, Genever R. BMJ 2010;341
7. Acute management of PD patients with compromised swallow or NBM. Formulated by
PDNS North west.
8. Acute management of Parkinson’s patients. NHS Fife. 2011.
9. NHS Tayside guide to the administration of medicines in the peri-operative period June
2012
10. NHS Dudley Parkinson’s disease prescribing guidelines for use in primary and
secondary care. Access via: Parkinson’s Disease Prescribing Guidelines for use in
Primary and Secondary Care
9
Appendix 1
COMMON ORAL MEDICATIONS USED IN PARKINSON’S DISEASE
Type of Drug
Drug Name
How it Works
Precautions
Levodopa
Co-Careldopa
Co-Beneldopa
Sinemet
Madopar
L-dopa is the
precursor of
Dopamine. Can be
used at all stages of
the disease process.
Works well on
stiffness and
bradykinesia
Becomes less
effective over time.
Dyskinesia
Drowsiness
Hallucinations
Postural
hypotension
Dopamine Agonist
Pramipexole
Ropinerole
Stimulates post
synaptic
dopaminergic
receptors
Nausea/vomiting
Hallucinations
Impulse Control
Disorder
Confusion
Monoamine
oxidase type B
(MAO-B) inhibitors
Selegiline
Rasagiline
Slows the
metabolism of
Dopamine
Drug is a stimulant,
therefore should be
taken in the morning
COMT inhibitors
Entacapone
Stalevo
Blocks the
metabolism of
Dopamine
Will increase side
effects of L-dopa
Anticholinergics
Trihexyphenidyl
(Benzhexol)
Blocks the action of
Acetylcholine (which
breaks down
Dopamine)
Limited efficacy
Neuro-psychiatric
side effects
Glutamate Agonist
Amantadine
Enhances the
release of
Dopamine.
Anticholinergic
properties
Mild effect
Short lived
Insomnia
10
Appendix 2
COMMONLY USED DRUGS TO AVOID
If patient already stabilised on therapy review and monitor
Table highlighting drugs to avoid (and use) when treating hallucinations and nausea:
Drug
Chlorpromazine
Treatment of
Hallucinations
/Confusion
X
Fluphenazine
X
Perphenazine
X
Trifluoperazine
X
Flupenthixol
X
Haloperidol
X
Quetiapine

Clozapine
(specialist initiation
only)

Treatment of
Nausea / Vomiting
Metoclopramide
X
Prochlorperazine
X
Domperidone

Cyclizine

Ondansetron

Vigilance is
required with the
use of
Antihistamines
¹
Antidepressants
¹
Antipsychotics
¹
Antihypertensives
e.g Calcium
Channel Blockers
¹
Key:
x–
–
¹ –
Not recommended
Recommended
Vigilance required
11
Appendix 3
CONVERSION ALGORITHM
Algorithm for estimating equivalent Levodopa dosages for Rotigotine patch
This is the Parkinson’s UK validated calculation tool for conversion of oral Parkinson’s
medications to transdermal patch. This has been incorporated into the online Rotigotine
convertor.
1. Calculate adjusted Levodopa
Equivalent Daily Dose (LEDD):
[(A) + (B)] x 0.55 = -------mg
(A) Total adjusted daily
Levodopa dose.
Total daily Levodopa dose in mg
(excluding Benserazide or
Carbidopa).
X 0.7 (if MR/CR) or
(B) Total adjusted daily
Dopamine agonist estimate
Levodopa equivalent dose
Total daily Dopamine agonist in
mg
X 100 (if on Pramipexole/
Cabergoline/ Pergolide
X 1.3 (if on COMT inhibitor) or
X 20 (if on Ropinerole)
X 0.91 (if MR/CR and on COMT
inhibitor)
X10 (if on Bromocriptine/
Apomorphine
= ------mg
= ------mg
(the above figures refer to each
medications Levodopa equivalent
factor)
2. Calculate dosage for Rotigotine transdermal patch
= Adjusted LEDD / 20 = ------mg




Maximum Rotigotine dose of 8mg in 24hrs (for monotherapy)
Maximum Rotigotine dose of 16mg in 24hrs (Adjunctive therapy)
Round to the nearest 2mg (max of 16mg) and prescribe as 24hr patch
DO NOT CUT PATCH. Available as 1mg//2mg/3mg/4mg/6mg/8mg patches (can use
more than one patch).
12
Appendix 4
CONVERSION CHARTS
Conversion table for Dopamine Agonists
Ropinirole
Controlled
Release
Ropinirole
Rotigotine
transdermal
patch
0.088mg tds
Starter pack
N/A
2mg/24 hrs
0.25mg tds
0.18mg tds
1mg tds
4mg/day
4mg/24hrs
0.5mg tds
0.35mg tds
2mg tds
6mg/day
6mg/24hrs
0.75mg tds
0.53mg tds
3mg tds
8mg/day
8mg/24hrs
1mg tds
0.7mg tds
4mg tds
12mg/day
10-12mg/24hrs
1.25mg tds
0.88mg tds
6mg tds
16mg/day
14mg/24hrs
1.5mg tds
1.05mg tds
8mg tds
24mg/day
N/A
Pramipexole
(salt content)
Pramipexole
(base content)
0.125mg tds
Conversion table for Levodopa
Current Levodopa regime (standard
release)
Rotigotine transdermal patch equivalent
Co-Beneldopa or Co-Careldopa 62.5 bd
2mg/24hrs
Co-Beneldopa or Co-Carel dopa 62.5 tds
4mg/24hrs
Co-Beneldopa or Co-Careldopa 62.5 qds
6mg/24hrs
Co-Beneldopa or Co-Careldopa 125 tds
8mg/24hrs
Co-Beneldopa or Co-Careldopa 125 qds
10mg/24hrs
Conversion table for Stalevo
Current Stalevo regime
Rotigotine transdermal
patch equivalent
Dispersible Co-Beneldopa
(May need to give smaller,
more frequent dosing)
50/12.5/200 tds
6mg/24hrs
62.5mg qds
100/25/200 tds
10mg/24hrs
≡125mg qds
100/25/200 qds
14mg/24hrs
≡125 mg 5 times daily
150/37.5/200 tds
16mg/24hrs
≡ 125 mg 6 times daily
13
APPENDIX 5 – REVIEW AND MONITORING ADHERANCE TO GUIDELINES
Lead
Tool
Frequency
Reporting
Arrangements
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to
be shared
Adherence
to this
guideline
through
actual and
near miss
incident
reporting
All Health
Care
Professionals
DATIX
Incident
Reporting
System
Quarterly
Quarterly
Aggregated Report
of Incidents to the
Clinical Quality
Safety and Patient
Experience
Committee
Depending on
Compliance, outcome
and clinical or
operational area –
Director Lead or
Manager assigned.
Directorate
Risk
Management
Groups
Inpatient
audit
Alison
Waldron
Audit
Every 6
months
Report to
Directorate
Depending on
outcome – Lead
Consultant will act