CLINICAL GUIDELINE
Document No: CG44
*All Sites
ACUTE MANAGEMENT OF PARKINSON’S PATIENTS
TITLE
Acute Management of Parkinson’s patients
Version:
1
Approved by: Clinical Standards Sub
Group
Date:
21/01/2014
Author/lead responsible for guideline:
Specialist nurse – Parkinson’s Disease
(Zenita Cowen) & Clinical Pharmacist (Vivien
Horton)
Date issued:
March 2014
Review date:
March 2016
Target audience:
All staff
Amendments and Additions
Replaces/supersedes:
Associated Policies:
N/A
Acute Management of Parkinson’s patients
RISK OF HARM IF MEDICATION OMITTED
Authors: Zenita Cowen Specialist Nurse Parkinson’s Disease and Vivien Horton Specialist Clinical Pharmacist
Date of Issue: March 2014
Date of review: March 2016
Contents
1. Introduction
2. On admission to hospital
3. If your patient has compromised swallow or is nil by mouth
4. Advice regarding Levodopa products
5. Advice regarding Dopamine Agonists
6. Switch guidelines
1. Levodopa
2. Stalevo
3. Dopamine agonists
4. Less commonly used dopamine agonists
7. Apomorphine infusion
8. Duodopa
9. Conclusion
10. Contacts
Authors: Zenita Cowen Specialist Nurse Parkinson’s Disease and Vivien Horton Specialist Clinical Pharmacist
Date of Issue: March 2014
Date of review: March 2016
1. Introduction
This document has been devised to provide guidance to staff who are involved with the
care of a patient with Parkinson’s and the Parkinson’s Specialist Team is unavailable
eg weekend or out of hours. It can be used in the first 48 hours; however advice
should be taken from the patient’s own specialist (Consultant Neurologist or
Parkinson’s Disease Nurse Specialist (PDNS)) as soon as possible.
Medication is crucial to the optimal management of Parkinson’s. If medication is not
given this can lead to patients being unable to swallow and so be at high risk of
aspiration, be unable to speak, move and become more dependant on staff. Patients
may also be at increased risk of falls, be in more pain and distress. At the worst it may
develop into neuroleptic malignant syndrome which can be fatal.
Parkinson’s patients are admitted to hospital for many reasons, often unrelated to their
Parkinson’s but if not managed appropriately this can lead to delayed recovery,
delayed discharge and poor outcomes for patients and their families.
Please use these guidelines to provide some anti-parkinsonian medication until your
patient can be seen by a member of the Parkinson’s Team to provide specialist advice
on complex medicines management.
2. On Admission to Hospital
1. Check drug history – the following sources can be used:
 Patient
 Family/ carer
 Medication brought in (Patient’s Own Medication green bag)
 Consultant’s letter
 PD nurse
 GP
 Electronic Summary Care Record
 Community pharmacist
 Residential/nursing home
 District nurse
2. Doses must be checked carefully.
3. Ensure the correct preparation is prescribed eg standard, dispersible, modified
release.
4. Timings of medication - Regimes are individual, it is therefore essential to give at
patient’s times not ward medication round times.
5. Obtain medication as soon as possible.
a. If the patient has brought their own medication and it is suitable, please use
this; see ‘Use of Patient’s Own Medication’ G34C
b. These are critical medication and may be ordered from pharmacy as such.
Authors: Zenita Cowen Specialist Nurse Parkinson’s Disease and Vivien Horton Specialist Clinical Pharmacist
Date of Issue: March 2014
Date of review: March 2016
c.
Acute areas/wards which hold stock of commonly used Parkinson’s
medications include; Emergency Cupboard and Ward 25.
6. DO NOT STOP PARKINSON’S MEDICATION!
7. If on Duodopa, Apomorphine or Rotigotine patch, continue as prescribed.
8. Do not prescribe medication which can worsen Parkinson’s symptoms e.g.
metoclopramide, haloperidol, prochlorperazine, cyclizine. If your patient requires
antiemetics, please use domperidone (tablets or liquid). Or ondansetron may be
used (unlicensed indication).
For clarification of medication you may need to contact your pharmacist.
Authors: Zenita Cowen Specialist Nurse Parkinson’s Disease and Vivien Horton Specialist Clinical Pharmacist
Date of Issue: March 2014
Date of review: March 2016
3. If your patient has compromised swallow or is nil by mouth
Speech and Language Therapy are not available out of hours but please contact them as
soon as possible.
Can your patient
swallow
tablets/capsules
safely?
Yes
Give usual medication
at correct times.
No
Could your
patient swallow
dispersible
tablets?
Yes
Convert to
dispersible
Madopar
No
Is a nasogastric tube
indicated?
Yes
Crush/disperse tablets
(unlicensed use)
No
Convert to rotigotine patch
(product licensed up to
8mg/24hours for monotherapy,
larger doses may be needed and
would be unlicensed, max
16mg/24h)
Review treatment
efficacy and amend
treatment as
needed
Refer to PDNS and
patient’s
neurologist asap
If your patient is on both levodopa AND a dopamine agonist and the combined equivalent dose of
rotigotine patch would be more than 16mg/24h (max dose), they may need a nasogastric tube
passing to allow administration of equivalent dispersible levodopa dose and use a rotigotine patch
for the equivalent dose of dopamine agonist.
Authors: Zenita Cowen Specialist Nurse Parkinson’s Disease and Vivien Horton Specialist Clinical Pharmacist
Date of Issue: March 2014
Date of review: March 2016
4. Advice regarding Levodopa products
Medication which may be given as dispersible/via nasogastric tube as follows:
Brand Name
Sinemet
Generic Name
Co-careldopa
Alternative
Disperse cocareldopa
Or use Madopar
dispersible
Madopar
Co-beneldopa
Madopar dispersible
Stalevo
Levodopa/carbidopa/entacapone Madopar dispersible
Dose
Convert
according
to
Levodopa
dose as a
minimum
Modified release preparation MUST NOT be crushed/dispersed in water.
For patients on modified release preparations, convert dose to dispersible tablets (the
frequency of administration may need review). When switching from modified release
levodopa to dispersible, a dose reduction of around 30% is suggested due to lower
bioavailabilty of modified release form (in practice this may need rounding to the nearest
tablet strength available).
Rescue
Dispersible Madopar 62.5mg may be prescribed as a rescue dose prn.
Antiemetic
Only use domperidone; this should be liquid 10 - 20mg tds via N.G. tube.
(It is possible to use ondansetron IV 4mg if necessary).
Medication which may be safely omitted until able to swallow:
 C.O.M.T. Inhibitors - Entacapone / Tolcapone
 M.A.O.B. Inhibitors - Selegiline/ Rasagiline
 Amantadine (Symmetrel)
5. Advice regarding Dopamine Agonists:
Brand Name
Rotigotine patch
Advice
Continue
Apomorphine s/c
(injection or
infusion)
Pramipexole
Continue. Use familiar pump if unsure of Apo-go pump. DO
NOT STOP!! APO-go Helpline 08448801327
Pramipexole PR
Convert to standard dose Pramipexole and crush as above
Ropinirole
Maintain same dose, crush tablets **
Ropinirole XL
Convert to standard dose Ropinirole and crush as above
Maintain same dose, crush tablets **
Authors: Zenita Cowen Specialist Nurse Parkinson’s Disease and Vivien Horton Specialist Clinical Pharmacist
Date of Issue: March 2014
Date of review: March 2016
Pergolide
Maintain same dose, crush tablets **
Cabergoline
Maintain same dose, crush tablets **
Bromocriptine
Maintain same dose, crush tablets **
** Unlicensed use.
Crushing of tablets should only be considered for short term use, i.e. first 48 hours
of admission until the patient can be reviewed by a specialist, for prolonged use or if
crushing tablets blocks the N.G. tube see alternatives in this pathway.
6 Switch Guidelines
Please note the following is provided for the purposes of guidance, if you have concerns
about side effects for eg a frail patient you could consider rounding down to the next
smallest patch (to reduce the risk of side effects), and monitoring efficacy with a view to
increasing if well tolerated but Parkinson’s control not optimised.
6.1 Suggested conversions for levodopa preparations to equivalent patch treatment
Current Levodopa regimen (mg)
Rotigotine patch equivalent
Madopar or Sinemet 12.5/50 BD
2mg/24h
Madopar or Sinemet 12.5/50 TDS
4mg/24h
Madopar or Sinemet 12.5/50 QDS
6mg/24h
Madopar or Sinemet 25/100 TDS
8mg/24h
Madopar or Sinemet 25/100 QDS
10mg/24h
Madopar or Sinemet 37.5/150 TDS
12mg/24h
Madopar or Sinemet 37.5/150 QDS
16mg/24h
Madopar or Sinemet 50/200 TDS
16mg/24h
Madopar or Sinemet 50/200 QDS
16mg/24h (max daily dose)
100mg levodopa modified release is approximately equivalent to 2mg/24hr rotigotine,
therefore if your patient takes Madopar 62.5mg TID and Madopar CR 25/100 nocte the
equivalent rotigotine dose = 6mg/24hr.
If your patient is on both levodopa AND a dopamine agonist and the combined equivalent
dose of rotigotine patch would be more than 16mg/24h (max dose), they may need a
nasogastric tube passing to allow administration of equivalent dispersible levodopa dose
and use a rotigotine patch for the equivalent dose of dopamine agonist.
Rotigotine patches must be removed before MRI scan or cardioversion (this is to
avoid skin burns as the patch contains aluminium).
Authors: Zenita Cowen Specialist Nurse Parkinson’s Disease and Vivien Horton Specialist Clinical Pharmacist
Date of Issue: March 2014
Date of review: March 2016
6.2 Suggested conversion from Stalevo preparations to equivalent patch treatment.
Current Stalevo regimen
Rotigotine patch equivalent
Stalevo 50/12.5/200 TDS
4mg/24h
Stalevo 75/18.75/200 TDS
8mg/24h
Stalevo 75/18.75/200 QDS
10mg/24h
Stalevo 100/25/200 TDS
10mg/24h
Stalevo 100/25/200 QDS
14mg/24h
Stalevo 125/31.25/200 TDS
14mg/24h
Stalevo 150/37.5/200 TDS
16mg/24h
Stalevo 175/43.75/200 TDS
16mg/24h
Stalevo 200/50/200 TDS
16mg/24h
Rotigotine patches must be removed before MRI scan or cardioversion (this is to
avoid skin burns as the patch contains aluminium).
6.3 Suggested conversions for oral dopamine agonist doses to equivalent patch
treatment
Pramipexole*
Pramipexole MR*
Ropinirole Ropinirole Rotigotine
XL
Patch
Starter
pack
2mg od
2mg od
88microgram tds
260microgarms od
(125microgram tds) (375micrograms od)
180microgram tds
520microgarms od
(250microgram tds) (750micrograms od) 1mg tds
350microgram tds
1.05mg od
(500microgram tds) (1.5mg od)
2mg tds
530microgram tds
1.57mg od
(750microgram tds) (2.25mg od)
3mg tds
700microgram tds
2.1 mg od
(1mg tds)
(3mg od)
4mg tds
880mcg tds
2.62mg od
(1.25mg tds)
(3.75mg od)
6mg tds
1.05mg
3.15mg od
(1.5mg tds)
(4.5mg od)
8mg tds
*Pramipexole doses are expressed as base (salt).
4mg od
4mg od
6mg od
6mg od
8mg od
8mg od
12mg od
10-12mg od
16mg od
14mg od
24mg od
16mg od
If your patient is on both levodopa AND a dopamine agonist and the combined equivalent
dose of rotigotine patch would be more than 16mg/24h (max dose), they may need a
Authors: Zenita Cowen Specialist Nurse Parkinson’s Disease and Vivien Horton Specialist Clinical Pharmacist
Date of Issue: March 2014
Date of review: March 2016
nasogastric tube passing to allow administration of equivalent dispersible levodopa dose
and use a rotigotine patch for the equivalent dose of dopamine agonist.
Rotigotine patches must be removed before MRI scan or cardioversion (this is to
avoid skin burns as the patch contains aluminium).
6.4 Suggested conversions for less frequently used dopamine agonists
Cabergoline Pergolide
Rotigotine
Patch
0.5 mg od
125microgram tds 2mg od
1mg od
250microgram tds 4mg od
2mg od
500microgram tds 6mg od
3mg od
750microgram tds 8mg od
4mg od
1mg tds
10-12mg od
5mg od
1.25 mg tds
14mg od
7. Apomorphine
Under no circumstances should apomorphine be initiated without the involvement of a
Parkinson’s Specialist.
If a patient is admitted and is on apomorphine please see the shared care protocol
(available via Map of Medicine, shared care protocols, neurology).
8. Duodopa
Duodopa intestinal gel (for use with an enteral tube) should be continued as prescribed.
Please seek advice from the Parkinson’s Specialist.
9. Conclusion
This document has been produced following recognition of serious adverse events,
including death, due to omission of Parkinson’s medication. Appropriate management of
Parkinson’s during hospital admission is essential to avoid potential problems with delayed
recovery, complications, delayed discharges and poor experiences for patients. Please
contact the Parkinson’s Specialist Team at the earliest opportunity to discuss your patient’s
care.
Authors: Zenita Cowen Specialist Nurse Parkinson’s Disease and Vivien Horton Specialist Clinical Pharmacist
Date of Issue: March 2014
Date of review: March 2016
Acknowledgements
North West Parkinson’s Disease Nurse Specialists in collaboration with pharmacists
with a specialist interest in P.D
Joy Reid, Fife Parkinson’s Service
Many thanks for sharing these guidelines and allowing use within South Tees NHS
Foundation Trust.
References:
British National Formulary No:65: March 2013
Summary of Product Characteristics for individual products: www.medicines.org.uk
Handbook of Drug Administration via Enteral Feeding Tubes. White, Rebecca; Bradnam,
Vicky. Pharmaceutical Press. Second edition. November 2010
Managing Parkinson’s disease during surgery. KA Brennan, RW Genever, BMJ
2010;341:c5718
Contacts:
Zenita Cowen – Specialist Nurse Parkinson’s Disease
Telephone - 01642 854319 (54319)
Email – zenita.cowen@stees.nhs.uk
Sue Palfreeman – PD Liason Sister
Telephone - 01642 854319 (54319)
Email – sue.palfreeman@stees.nhs.uk
Neil Archibald – Consultant Neurologist
Telephone – 01642 835808
Email - neil.archibald@stees.nhs.uk
Vivien Horton – Pharmacist
Telephone – 01642 854795 (54795)
Email – vivien.horton@stees.nhs.uk
Authors: Zenita Cowen Specialist Nurse Parkinson’s Disease and Vivien Horton Specialist Clinical Pharmacist
Date of Issue: March 2014
Date of review: March 2016