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Parkinson’s: Key information for hospital pharmacists Introduction

There are 127,000 people living problems that may or may not be with Parkinson’s in the UK1. related to a person’s Parkinson’s. There’s no cure for Parkinson’s, but medication can substantially An admission may be planned, but improve symptoms. it may also be as an emergency. In England, people over 65 with Medication routines can be Parkinson’s are three times more complex and because Parkinson’s likely to have an unplanned is a progressive condition, these admission to hospital than over routines are regularly reviewed 65s without the condition2. by specialists and adjusted to Therefore it is likely that you will maintain their benefits. see a person with Parkinson’s in your hospital. If not enough attention is paid to Parkinson’s medication, At Parkinson’s UK, we’re eager symptoms can become poorly to work with pharmacists and controlled and people’s condition their teams in hospitals to draw can deteriorate. attention to the importance of effective medicines management This can happen even within a in Parkinson’s. short period of time if appropriate review is not completed and the You can play a vital role in routine is not properly maintained ensuring people with Parkinson’s – during a hospital admission, achieve good control of their for example. symptoms with their medications and so have the best possible In 2012/13, people with outcome from a hospital Parkinson’s were admitted admission. to hospital 98,195 times in England2. Hospital admissions may be due to Parkinson’s, but it may also be due to other health

2 What is Parkinson’s?

Parkinson’s is a progressive are slowness of movement neurological condition. It’s more (bradykinesia), rigidity and rest common in the older population, tremor. Most drug treatments but some have been seen to aim to ease these motor develop symptoms before the symptoms. age of 40. However Parkinson’s is also The cause is unknown, but associated with many non-motor the pathophysiology is the symptoms which people often say degeneration of - cause them more distress in their producing cells in the everyday life than their motor substantia nigra. Dopamine is a symptoms. Non-motor symptoms and linked to are treated separately but it a range of neural pathways in is essential that care is taken the brain. The loss of nerve cells to make sure any medications producing dopamine affect these prescribed are compatible with neural pathways and cause the existing prescriptions and the symptoms of Parkinson’s most appropriate medications are to appear. The symptoms most used for presenting symptoms. often associated with Parkinson’s

3 Managing Parkinson’s with medications

Most people with Parkinson’s • stimulating post-synaptic use medication to control their receptors that would normally symptoms. The most commonly be activated by dopamine used medicines are shown in ( group) Appendix 1 on page 20. • blocking the action of enzymes and that They compensate for the loss break down dopamine of the dopamine-producing neurons by: Parkinson’s affects everyone differently in terms of how • increasing the levels of symptoms present and the speed dopamine in the brain and nature of its progression. (levodopa group)

4 As shown in Appendix 1 (page simple everyday activities such 20), the options for treatment as walking and eating – within are wide-ranging, so medication a hospital setting, this could mean routines may vary significantly that staff are required to give between different people with more assistance. Swallowing may Parkinson’s. also be affected which could lead to problems taking further doses. In addition, routines will usually need adjusting as the person’s In extreme cases, missed doses symptoms change over time and may lead to the potentially the condition progresses. fatal neuroleptic-like malignant syndrome. Therefore it is important that people with Parkinson’s are Because of the complexity regularly reviewed by a specialist associated with Parkinson’s (who may be a consultant medication, ensuring an individual neurologist, geriatrician, is able to maintain their prescribed Parkinson’s nurse or specialist medication routine in terms of pharmacist) to ensure they are the right preparation, dosage and getting the right treatment timing is a challenge. for them. However there is much that you The key issue with Parkinson’s can do as a hospital pharmacist medication is timing. Medication to ensure that routines are needs to be taken at specific maintained and people with times so that symptoms are Parkinson’s get the most out of controlled and can be maintained an admission into hospital. without deterioration.

Not getting medication on time can mean the difference between someone being able to function independently and someone becoming reliant on others for

5 Your role as a hospital pharmacist

Support maintenance of • information about medication prescribed medication routes routines might not be readily 1 accessible (particularly with an Medication routines prescribed emergency admission or if the for Parkinson’s can vary between person is transferred between individuals in the types of departments) preparation, the dosages given the medications that a person and the time at which they •  with Parkinson’s is taking might are taken. not be easily available It may have taken some time • the medication routines may to establish a routine that best not fit easily with hospital suits a person and it is vital this procedures, such as timings is maintained so symptoms are of traditional drug rounds or controlled effectively. But this can theatre schedules for surgery be difficult in hospitals because:

6 Disruption to someone’s not well managed3. Measures medication routine can have should be taken to ensure that significant implications both for people with Parkinsons ALWAYS the person with Parkinson’s and get the correct medication at the level of support they require the correct time to minimise the from ward staff. Parkinson’s UK consequences of missed or launched the Get It On Time late doses. campaign to raise awareness of how vital it is that people You may find the following useful: with Parkinson’s receive their medication on time in hospitals • Liaise with medical and nursing and in care homes. You can find colleagues to make sure they out more about the campaign at have a comprehensive list of parkinsons.org.uk/getitontime a person’s medication (with information about preparations, In 2012/13 people with dosages and timings). This can Parkinson’s spent a total of help accurate prescribing and 128,513 excess days in hospital administration for everyone at a cost of more than £20 involved in managing the million2. While it is difficult to person’s medication. People determine to what extent this with Parkinson’s and their was due to poor medicines carers are usually aware of how management, it demonstrates important their medication is that managing admissions of in managing their condition people with Parkinson’s is already and may have this information a challenge in hospitals. This issue with them. Make sure you was also highlighted in the Rapid ask them about this as well Response Alert published by the as looking at any formal National Patient Safety Agency documentation there is on in 2010 on reducing harm from the person. Because of the omitted and delayed medicines importance of medications in hospital. The report identified in managing Parkinson’s, people with Parkinson’s being medicines reconciliation should at risk when their medicines are be a priority for this group

7 of patients. This includes ingredients5. The differences admissions that occur outside between formulations are normal working hours, so it’s is small and controlled through important that out-of-hours regulation, but they still might procedures support prompt be clinically significant in terms review by pharmacists. of symptom control. If this • Make sure a wide range of does occur – because of local Parkinson’s medication is availability of medications, for stocked or that you are aware example – explain to the person of how and where to get and/or their carer why supplies so that it is readily a different preparation has been available to help maintain dispensed to help reduce any individual routines. People with or confusion. Parkinson’s are encouraged • Assess patients to see if they to bring a small supply of are able to self-administer their medication in its original medication and support them packaging to hospital with them to do so if they are clinically so that it can be used during able. A person’s capability to an admission, however this do this may change during may not be available if they an admission, such as in the are admitted in an emergency. immediate post-operative Parkinson’s medications stage, so it is important should be on the trust’s critical that information about medicines list so that supplies their self-administration can be accessed at any time3. status is accurately updated • Use branded preparations on all documentation and where prescribed and don’t communicated to all relevant substitute with generic staff. However the aim should versions. These may vary always be to encourage in both the level of active people with Parkinson’s to ingredients4 and the effect be as independent with their of non-active components medications as possible. on the absorption of active

8 • Print out timings on the a person with Parkinson’s gets pharmacy label or add them to their medication on time even any blister packs issued to help if this does not fit in with the ensure ward staff can support usual timings of drug rounds or people with Parkinson’s to get if this coincides with other ward their medication on time. activities, such as mealtimes. Surgery or clinical tests will Ensure that other hospital •  also need to be planned around staff caring for a person with the timings of someone’s Parkinson’s understand the medication routine. Ideally, importance of keeping to someone should be put at the prescribed medication the start of operating lists to routine and adjust activities optimise their medication. It accordingly. For example, ward should be noted that people staff will need to ensure that

9 with Parkinson’s can still take All of these are available prescribed oral medication to view and order from with small amounts of clear parkinsons.org.uk/publications fluids up to two hours before Investigate if a person elective surgery6. In addition, •  with Parkinson’s is having anaesthetists may wish to difficulty taking their usual consider regional anaesthesia oral medication and manage rather than general anaesthetic it accordingly. Common issues as this would allow continuation include: of the usual medication routine. As patients may transfer  Swallowing problems – between areas of the hospital management may include during their admission, it may considering posture for an be necessary for you to advise a effective swallow (ie sitting range of staff in different wards upright with chin neutral), or departments. Parkinson’s review by a speech and UK have various resources language therapist, use of that might help you explain thickened fluids or soft food the importance of timing of to facilitate swallow or use of medication to other staff – liquid or dispersible versions of these include: drug preparations (N.B. never crush or split modified release  Caring for your patient preparations (labelled CR, MR, with Parkinson’s (booklet for XL or PR)) ward staff)  /vomiting or altered level  Medicines management for of consciousness/confusion/ patients with Parkinson’s agitation/ hallucinations. (DVD for ward staff) In these incidences, it is important to first check  Emergency management for any previous history or of patients with Parkinson’s underlying cause (including (pocket guide for those who infection or dehydration) and may manage a person with treat accordingly. However Parkinson’s within an if medication is used, it emergency setting)

10 is important to only use dopamine plays a role in neural preparations that do not worsen pathways involved in cognition, Parkinson’s symptoms (See arousal, motivation and reward. ‘Make sure other medications do not make Parkinson’s Common symptoms include pain, symptoms worse’ on page 14) fatigue, mental health issues (such as depression and anxiety),  If a person is still not able to take their next prescribed oral autonomic dysfunction, sleep dose, it may be necessary to problems and bladder and bowel consider administration via problems including a naso-gastric, naso-jejunal (this is particularly problematic in or PEG tube, or via Parkinson’s as this can affect the patches (See Appendix 2 on absorption of medications which page 24) in turn can worsen symptoms). It is important to treat these Some people with Parkinson’s symptoms appropriately taking may also be using non-oral particular care not to use medications or have had surgery medications that can worsen to help them control their motor symptoms (See ‘Make sure symptoms. More details about other medications do not make these can be found in Appendix Parkinson’s symptoms worse’ on 3 on page 28. Maintaining a page 14). It may be helpful to consistent medication routine will consider non-pharmacological help people with Parkinson’s get interventions including advice the most out of their medication about sleep hygiene and referral whilst they are in hospital. to other professionals, such as dietitians, to manage these Understand the wide-ranging symptoms effectively. impact of Parkinson’s and its medications People using levodopa to manage 2 their Parkinson’s may notice that People with Parkinson’s can over time their medication is not experience a wide range of non- as effective as it once was. When motor symptoms. This is because symptoms are well controlled with

11 12 levodopa, people with Parkinson’s the incidence of are experiencing an ‘on’ period. (whilst making sure that any As the body metabolises the reduced dose is still achieving drug, symptoms become less symptom control) well-controlled and the person • where symptom control may have an ‘off’ period. If this is problematic, it may be happens, many people start to advisable for people not to take find their movements becoming their medication with meals as stiffer – some may even protein may inhibit levodopa become completely unable to absorption move. These motor fluctuations are best managed by taking • managing any underlying issues medication at regular intervals. that might affect levodopa As the condition progresses, absorption, such as constipation people may well have increasing or timings of any prescribed fluctuations between ‘on’ and iron supplements. Because ‘off’ periods and so medication of the potential formation of is needed more frequently. chelates in the gastrointestinal But increasing the amount of tract, it is advised that 2-3 levodopa may also increase hours is left between iron and the likelihood of the person levodopa preparations. developing dyskinesias. These are involuntary, uncontrolled Parkinson’s medications do have jerky movements that can affect potential side-effects you should any part of the body. Significant be aware of. These may include changes in Parkinson’s medication nausea, vomiting, drowsiness routines should be conducted by a and low blood pressure, which specialist, but possible strategies can lead to and you can try with a person with fainting. With some Parkinson’s Parkinson’s in hospital include: drugs, particularly dopamine agonists and in a small number • using smaller doses more of cases, levodopa, some frequently to reduce the ‘peaks people experience problems and troughs’ of levodopa and with impulsive and compulsive

13 behaviour. Examples of this • Parkinson’s can lead to behaviour may include gambling, difficulties in communication compulsive spending, binge such as quietening of the eating or hypersexuality. These voice, slurring of speech and behaviours can have a huge reduced facial expressions impact on people’s lives. If, during and body language. Therefore an admission, impulsive and it is important to ensure the compulsive behaviour is observed environment supports your or reported, it is important that patient to communicate as well medications are not suddenly as they can stopped as this may make other Parkinson’s can cause symptoms worse. Instead, people •  swallowing difficulties so it is with Parkinson’s and their family advisable to ask patients if they or carers should be encouraged are having any difficulty taking to speak to their specialists about their medication getting their medication reviewed at the earliest opportunity. • Adherence to medication routines can be affected if the Helpful resources about impulsive side-effects or any issues with and compulsive behaviour can taking the medication (such as be found at parkinsons.org.uk/ its taste or size) outweigh their icbsupport benefits from the point of view of the person. So asking your Other potential complications patient how their Parkinson’s which may be seen when a medication is affecting their person with Parkinson’s is ability to function is key to admitted to hospital or ‘red flag’ understanding how successful signs that would mean someone their current routine is in should be reviewed by a specialist improving their quality of life. are discussed in Appendix 4 on page 29. Other considerations Make sure other medications when managing a person with do not make Parkinson’s Parkinson’s include: 3symptoms worse7,8

14 People with Parkinson’s who are think through the mechanisms in hospital may have additional of action. Some drugs should be issues that may or may not be used with caution and the person caused by their Parkinson’s. closely monitored in case their While managing these effectively Parkinson’s symptoms get worse. is clearly a priority, it is also In other cases, some drugs should important to make sure that be avoided. medication given to manage these problems does not make For nausea and vomiting, avoid: their Parkinson’s worse. •  (Maxalon) Any drug that blocks dopamine • prochlorperazine (Stemetil) receptors could make the symptoms of Parkinson’s worse Domperidone (Motilium) is the or even mimic Parkinson’s anti-emetic of choice to prevent symptoms without the condition and treat nausea and vomiting. being present. When introducing A European review in 2014 any new medications for patients found a small increased risk of with Parkinson’s, it’s important to

15 serious cardiac side effects with For coughs and colds, avoid: domperidone and so advised that it is contraindicated in people • preparations containing with known cardiac conditions. sympathomimetics (such But the advice also highlighted as pseudoephedrine and the need to take into account ephedrine) with MAO-B the overall safety profile of inhibitors domperidone with the clinical need for its use with particular Vigilance is particularly required reference to Parkinson’s9. If an with use of: injectable or alternate anti-emetic is required, (Valoid) may • , especially be considered post-operatively. (Stugeron/Arlevert), Ondansetron can also be used which if used long-term, can although a common side-effect mimic Parkinson’s symptoms 10 is constipation – in addition, it • antidepressants is contraindicated if the person is using because of •  the risk of hypotension10. • antihypertensives, such as diltiazem (Adizem/Angitil/ For hallucinations/confusion, Calcicard/Dilcardia/Dilzem/ avoid: Solzem/Tildiem/Viazem/ Zemtard) and other calcium •  (Largactil) channel blockers. Note that • fluphenazine (Modecate) these should also be monitored by the GP clinical system • perphenazine (Fentazin) • trifluoperazine (Stelazine) More information about potential • flupenthixol (Fluanxol/Depixol) interactions with Parkinson’s medications can be found in • haloperidol (Serenace/Haldol) Appendix 1 of the British National Formulary. The NICE Clinical Refer to a specialist for review Knowledge Summaries service and management. also has information about which drugs to avoid with Parkinson’s8. 16 Support people to take As people with Parkinson’s control post discharge often have close links with their 4 community pharmacy, supplying If there have been any changes clear information about any to a person’s medication routine changes would also be useful to while they have been in hospital, your colleagues in this setting. make sure you inform the person with Parkinson’s and their carers Because of the complexity what changes have been made, of Parkinson’s medication, a why they were needed and if they medicines review could help make should look out for any specific sure a person’s medication routine side-effects. In addition, it is very continues to work for them. important that clear information about medication on discharge A national target area for the is sent to the person’s GP to Medicines Use Review (MUR) prevent any medication errors scheme in England is patients who following an admission. have recently been discharged

17 from hospital and have had their and emotional support to people medication routine changed11. with Parkinson’s, their families and carers. In addition, the network of Communicating with the person’s local groups enables people with community pharmacist to Parkinson’s and their carers to schedule in a medicines review meet others and get involved following their admission is an in activities to enable them to excellent way of strengthening take control. your connections with community-based care. The Parkinson’s UK website has information about local support Parkinson’s is a lifelong condition teams and our local groups at for which there is currently no parkinsons.org.uk/localtoyou cure. However by accessing relevant information and support, Find out more about there’s no reason why people who Parkinson’s have Parkinson’s cannot enjoy 5 a fulfilling and enjoyable life. The medical specialist managing your patient with Parkinson’s may Parkinson’s UK provides a range be a neurologist or a geriatrician. of services for both people They may have contact with affected by Parkinson’s and a specialist Parkinson’s nurse those around them. or a specialist pharmacist.

These include a confidential Knowing who these local experts helpline (0808 800 0303) are and their contact details will and a range of publications be useful should you need to seek which can be ordered from specialist advice. parkinsons.org.uk/publications Parkinson’s UK not only provides Parkinson’s UK also offers information and support to people support locally across the UK. affected with Parkinson’s, it also Parkinson’s Local Advisers can provides specific support offer one-to-one information to professionals.

18 The UK Parkinson’s Excellence There are also national guidelines Network allows you to keep about the management of up-to-date with the latest Parkinson’s that may be useful news, events and learning in your practice. These can be opportunities, such as courses found at nice.org.uk (note that and Q&A sessions with renowned the NICE guidelines are currently experts, information resources under review and are due to be and service improvement tools published in October 2016) and to enable you to provide the best sign.ac.uk (Scotland) possible care for people affected by Parkinson’s. More details can be found at parkinsons.org.uk/ excellencenetwork

Education is also provided in partnership with other organisations. For example, a session has been developed with the Centre for Pharmacy Postgraduate Education about Parkinson’s and its medication as part of their ‘learning at lunch’ series. For more details, go to www.cppe.ac.uk

There are pharmacy networks with a special interest in Parkinson’s and/or neurology, such as the United Kingdom Clinical Pharmacy Association Neurosciences group. More details can be found at www.ukcpa.net

19 Appendices

Appendix 1 Drug treatments for Parkinson’s Note that some people might require different preparations of the same drug, e.g. standard release levodopa medication during the day and a modified release version at night.Please note that other branded versions may be available through your local formulary.

levodopa and levodopa 100ml per cassette (Co-careldopa) containing 2000mg DUODOPA levodopa and 500mg (Intestinal gel) carbidopa monohydrate

Levodopa and 25mg/100mg ** carbidopa 12.5mg/50mg CR 50mg/200mg (Co-careldopa) 25mg/250mg SINEMET Half-CR** 10mg/100mg 25mg/100mg

Levodopa, 50mg 150mg carbidopa 75mg and 175mg STALEVO 100mg 200mg 125mg

Carbidopa and levodopa (Co-careldopa) 100/25mg 200/50mg LECADO

Carbidopa and levodopa (Co-careldopa) 25/100mg 50/200mg CARAMET

Co-careldopa also available in generic form. If you would like more information about Madopar, please contact Roche at 01707 366000

20 CATECHOL-O-METHYL TRANSFERASE INHIBITORS (COMT inhibitors)

Entacapone COMTESS 200mg

Tolcapone TASMAR 100mg

NB rarely prescribed (see Appendix 4) DOPAMINE AGONISTS

Apomorphine APO-go PEN (Intermittent injection) 3ml (10mg/ml)

Apomorphine 10ml (5mg/ml) APO-go PFS (Pre-filled syringe) Crono APO-go pump

Apomorphine 5ml amp (10mg/ml) APO-go (Ampoules) Crono APO-go pump

Ropinirole 1mg REQUIP 0.25mg 0.5mg 2mg (in starter (in starter pack only) pack only) 5mg

Ropinirole REQUIP XL (Prolonged release) XL 2mg XL 4mg XL 8mg

Rotigotine NEUPRO (Patches) 2mg/24h 4mg/24h 6mg/24h 8mg/24h

21 DOPAMINE AGONISTS continued

Pramipexole 0.088mg base/ 0.35mg base/ MIRAPEXIN 0.125mg salt 0.5mg salt

0.18mg base/ 0.7mg base/ 0.25mg salt 1mg salt

0.26mg base/ 0.375mg salt 2.1mg base/ 2.62mg base/ MIRAPEXIN 0.52mg base/ 3.0mg salt 3.75mg salt PROLONGED 0.75mg salt RELEASE 1.05mg base/1.5mg salt 3.15mg base/ 1.57mg base/ 2.25mg salt 4.5mg salt

Bromocriptine PARLODEL 1mg 2.5mg 5mg 10mg NB rarely prescribed (see Appendix 4)

Cabergoline CABASER 1mg 2mg

NB rarely prescribed (see Appendix 4)

Pergolide

50mcg 250mcg 1000mcg NB rarely prescribed (see Appendix 4) Apomorphine, ropinirole, , , and pramipexole also available in generic form. Be extra vigilant about dispensing the correct strength of pramipexole (note that the dose is expressed in terms of the salt and the base).

Anticholinergics

Procyclidine 2.5mg/5ml hydrochloride ARPICOLIN 5mg/5ml

Orphenadrine hydrochloride (Generic) 50mg/5ml

Also (Kemadrin). Procyclidine hydrochloride and are available in generic syrup and tablet form. Care needed when prescribed because of potential side effect of memory loss10

22 B INHIBITORS (MAO-B inhibitors)

Rasagiline AZILECT 1mg

Selegiline ELDEPRYL 5mg or 10mg

Selegiline ZELAPAR 1.25mg

Selegiline also available in generic form. Glutamate antagonist

Amantadine SYMMETREL (Capsules or syrup) 100mg 50mg/5ml

• Please note the images of the tablets and capsules are not representative of their actual size. • This does not give an exhaustive list of products used to treat Parkinson’s.

†details current for August 2015. **CR (controlled release) drugs are complete doses. Tablets and capsules should not be broken or split.

23 Appendix 2 Administration of Parkinson’s medications via non-oral mechanisms

Priority is maintenance of medication

Administration via naso-gastric, naso-jejunal or PEG tube:

• Assess for any contraindications. • Insert as per local protocol.

The objective is to continue short term management of Parkinson’s with the most appropriate therapy (prioritising dopaminergic medication) given the level of access a patient has. You should consult with a specialist about alternative methods if long term non-oral administration of medication required.

• The table below identifies common licensed proprietary use of each medication. Consult your local guidelines for further advice. • For medication given in liquid form, flush tube afterwards to ensure complete administration and to prevent blockages. • Return to usual medication routine (and routes of administration) as soon as clinically possible.

Levodopa (main site of absorption is the jejunum – naso-gastric recommended) Co-beneldopa (Madopar) Use dispersible versions. For CR doses, because of reduced bioavailability, convert to dispersible equivalent by multiplying total daily levodopa dose by 0.7 and rounding to nearest available dispersible preparation6 – monitor as dose frequency may need to be altered accordingly.

24 Co-careldopa (Sinemet/Lecado/Caramet) Use dispersible co-beneldopa versions (using equivalent dosage of levodopa). For CR doses, use co-beneldopa dispersible equivalent conversion equation (see above) Co-careldopa and entacapone (Stalevo) Treat co-careldopa constituent of Stalevo as above (ie administer equivalent dispersible co-beneldopa dose). Entacapone not licensed for use in enteral feeding systems – can be usually safely omitted temporarily (see MAO-B/COMT inhibitors). Dopamine agonists Pramipexole (Mirapexin); Ropinirole (Requip); Bromocriptine (Parlodel); Cabergoline (Cabaser); Pergolide. Not licensed for use in enteral feeding systems. Consider rotigotine patches as substitute for dopamine agonist medication. MAO-B/COMT inhibitors Selegiline (Eldepryl/Zelapar) Use equivalent dose of liquid form of Eldepryl – for naso-jejunal tubes, dilute with equal volume of water immediately prior to administration. (Azilect) (Tasmar) Entacapone (Comtess) Not licensed for use in enteral feeding systems – can usually be safely omitted temporarily. NB note information on Tolcapone in Appendix 4 on page 29 Glutamate Antagonist Use liquid version. NB Note information in Appendix 1 on page 22. hydrochloride (Disipal) Use liquid (generic) version. Procyclidine (Kemadrin) Use liquid (generic or Arpicolin) version.

25 Guide for estimating equivalent levodopa dosages for rotigotine patches.12

1. Calculate Adjusted Levodopa Equivalent Daily Dose (LEDD): [(A) + (B)] x 0.55 = ______mg

(A) Total adjusted daily (B) Total adjusted daily levodopa dose dopamine agonist estimate Total daily levodopa dose in levodopa equivalent dose mg (excluding or Total daily dopamine agonist carbidopa) in mg [eg Madopar 125mg X 100 (if on pramipexole/ QDS = 4x100=400mg/24h] cabergoline/pergolide) X 0.7 (if MR/CR preparation) X 20 (if on ropinirole/ or rotigotine) X 1.3 (if on COMT inhibitor) X 10 (if on apomorphine/ or bromocriptine) X 0.91 (if MR/CR preparation = _____mg and on COMT inhibitor) (the above figures refer to each medication’s = _____mg levodopa equivalent factor)

NB (A) or (B) = 0 if not taking that type of medication

2. Calculate dosage for rotigotine patch = Adjusted LEDD /20 = ____mg

• Round to nearest 2mg (to max of 16mg) and prescribe as 24-hour patch. • DO NOT cut patches – available as 2mg/4mg/6mg/8mg patches (can use more than one patch). Also available as 1mg/3mg but not licensed for use in Parkinson's.

26 • CAUTION – this calculation is for guidance only and is not a substitution for assessment of patient need – treat each person individually and adjust doses accordingly:

 if increased stiffness/slowness observed, increase dose and review daily  if increased confusion/hallucinations observed, decrease dose and review daily  If adjusted LEDD >350mg, use rotigotine 16mg and consult with specialist regarding administration of apomorphine.

27 Appendix 3 Non-oral treatments for Parkinson’s Apomorphine (APO-go) Apomorphine is a dopamine agonist administrated via an intermittent sub-cutaneous injection or a continuous subcutaneous infusion via a pump – it is not -based, is not an analgesic and is not a controlled drug.

Patients who are established on apomorphine need to be continued at the prescribed dose and frequency (injection) or rate (pump) – do not change the pump settings unless requested to do so.

For further support, call the APO–go helpline on 0844 880 1327 or contact the specialist (eg Parkinson’s nurse or specialist pharmacist).

Duodopa infusion This is co-careldopa (levodopa and carbidopa) in gel form delivered into the jejunum via a PEJ tube.

Patients who are established on a duodopa routine need to be continued at the prescribed rate providing gastric emptying is not delayed and the PEJ tube is patent. If not, discontinue and commence on rotigotine patches).

Deep brain stimulation (DBS)13 This involves stimulation of target sites within the brain (either in the thalamus, the globus pallidus or the subthalamic nucleus) through electrodes connected to a neurostimulator placed under the skin around the chest or stomach area. Patients who are established on DBS need to be maintained on the same routine.

For further support, contact the neurological department that implanted the system (the patient should carry a patient ID card listing contact details and model number of the DBS system).

28 Appendix 4 Complications with Parkinson’s14 •  (acute confusion due to drugs or infection) • Chest infection, especially aspiration pneumonia • Urinary tract infections • Postural hypotension and falls – check meds and BP lying/sitting then standing • Neuroleptic-like malignant syndrome

Red flags that means a patients needs to be referred to a Parkinson’s specialist15:

• fibrotic reactions with ergot-derived dopamine agonists (including bromocriptine, pergolide and cabergoline) where prescribed. For example dyspnoea, persistent cough, chest pain, cardiac failure, abdominal pain or tenderness (these patients should be having regular echocardiography and chest X-rays) • signs of liver disorder with tolcapone (if used), such as nausea, vomiting, fatigue, abdominal pain, dark urine, pruritus (these patients should be having regular liver function tests) • increased falling especially early in condition • hallucinations/dementia/depression/cognitive decline especially early in condition

29 References

1. Parkinson’s Disease Society (2009) Parkinson’s prevalence in the United Kingdom

2. Health and Social Care Information Centre. NHS Hospital Episode Statistic data 2011-12 and 2012-13

3. National Patient Safety Agency (2010) Rapid Response Report – Reducing harm from omitted and delayed medicines in hospital. NPSA/2010/RRR009

4. Gasser, U.E., Fischer, A., Timmermans, J.P., Arnet, I. (2013) Pharmaceutical quality of seven generic Levodopa/Benserazide products compared with original Madopar®/Prolopa®. BMC Pharmacology and Toxicology, 14:24

5. Go, C.L., Rosales, R.L., Schmidt, P., Lyons, K.E., Pahwa, R., Okun, M.S. (2011) Generic versus branded pharmacotherapy in Parkinson’s Disease: Does it matter? A review. and Related Disorders, 17 (5) 308-312

6. Brady, M, Kinn, S, Stuart, P, Ness, V (2009) Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev; 7; CD005285

7. Baxter, K. (2010) Stockley’s Drug Interactions: A source book of interactions, their mechanisms, clinical importance and management. Pharmaceutical Press; 9th edition

8. NICE Clinical Knowledge Summaries (2009) Parkinson’s disease [online]. Available from: http://cks.nice.org.uk/parkinsons-disease #!scenariorecommendation:28 [Accessed 13 August 2015]

9. MHRA (2014) Domperidone: risks of cardiac side-effects [online]. Available from: www.gov.uk/drug-safety-update/domperidone-

30 risks-of-cardiac-side-effects [Accessed 20 July 2015]

10. British National Formulary 69 – March 2015 – September 2015

11. Pharmaceutical Services Negotiating Committee (2015) National target groups for MURs [online]. Available from: http://psnc.org. uk/services-commissioning/advanced-services/murs/national- target-groups-for-murs/ [Accessed 13 August 2015]

12. Brennan, KA, Genever, RW (2010) Managing Parkinson’s disease in surgery. BMJ; 341: c5718

13. MacMahon, M.J MacMahon, DG (2012) Management of Parkinson’s Disease in the acute hospital environment. J R Coll Physicians, Edinb; 42: 157-62

14. Dr J George, Dr S Manickam, Judith Graham (PDNS) (2007) Emergency assessment of patients with Parkinson’s. North Cumbria Acute Trust

15. Wales Centre for Pharmacy Professional Education (2013) Quick practice guide for targeted MURs: Parkinson’s Disease

Thanks to

• Janine Barnes, Neurology Specialist Pharmacist, The Dudley Group Foundation Trust • Mark Gadsby, Locality Pharmacist, Betsi Cadwaladr University Health Board • Emma Grace, Senior Clinical Pharmacist, Nottingham University Hospitals Trust • Shelley Jones, Chair, Neurosciences Group, United Kingdom Clinical Pharmacy Association • Jenny Wright, Parkinson’s nurse, Nottingham University Hospitals NHS Trust.

31 The UK Parkinson’s Excellence Network is the driving force for improving Parkinson’s care, connecting and equipping professionals to provide the services people affected by the condition want to see.

The tools, education and data it provides are crucial for better services and professional development.

The network links key professionals and people affected by Parkinson’s, bringing new opportunities to learn from each other and work together for change.

Visit parkinsons.org.uk/excellencenetwork

L036 © Parkinson’s UK, September 2015 (RD1894). Parkinson’s UK is the operating name of the Parkinson’s Disease Society of the United Kingdom. A charity registered in England and Wales (258197) and in Scotland (SC037554).