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Management of Parkinson’s disease during periods of fasting

This guideline is aimed at the management of the patient with Parkinson’s disease who are undergoing an unplanned period of fasting. The two main examples of this are:

1. Inpatients who are unable to take their Parkinson’s medication due to lack of oral route availability a. Critical Care admission b. Gastrointestinal pathology 2. Patients undergoing surgery

A number of complications can occur if patients miss their dose of Parkinson’s medications. Even if doses are taken on time, the effect of the medication can be altered by impaired drug absorption via the oral route. Therefore, during admission if the oral route is unavailable for any of the above reasons an alternative route of administration should be sought. Regular oral medication should be restarted as soon as possible; sometimes a nasogastric feeding tube can be used. See appendix C “Administration of Parkinson’s medication in patients with feeding tubes” for drug conversions.

Planned admission

Consultation should occur with the patient’s usual movement disorder team prior to admission, this will enable their treatment to be individually tailored and a management plan put in place during their hospital stay.

Unplanned admission

1. Inpatients who are unable to take their Parkinson’s medication due to lack of oral route availability a. Critical Care Admission b. Gastrointestinal pathology

A referral should be made to the movement disorder specialist as soon as possible for review of medication

In the meantime convert the usual oral medication to an equivalent patch (Appendix A and B)

Avoid the use of medications which can worsen the symptoms of Parkinson’s disease

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Created: June 2015 Review: June 2017 Authors: Dr Siobhane Holden, Mrs Jenny Oakley and Dr Stephen Gilligan

2. Patient undergoing surgery

Pre-operative

 Obtain an accurate drug history  Continue clear oral fluids until 2 hours pre-operatively  Oral medication to be continued pre-operatively  Consider placing the patient at the start of the operating list and attempt to time fasting period between usual doses  Do not prescribe medications which can worsen Parkinson’s symptoms. I.e. Haloperidol

Intraoperative

 Avoid centrally acting antagonists e.g. Prochlorperazine, Metoclopramide  is preferable as an anti-emetic  and can be used  Consider regional anaesthesia where appropriate, the patient may be able to continue oral doses as normal with this technique

Postoperative

 Overall aim is to continue to take usual oral medication. Therefore if the patient will be eating and drinking before the next dose continue the medication as usual  If it is not possible for the patient to continue oral medication convert the usual oral dose to an equivalent rotigotine patch (Appendix A and B)

Contact the movement disorder specialist as soon as possible for review and initiation of further management plan

References

1. Brennan KA, Genever RW. Management of Parkinson’s disease during surgery. BMJ 2010;341:5718 2. MacMahon MJ, MacMahon DG. Management of Parkinson’s disease in the acute hospital environment. J R Coll Physicians Edinb. 2012;42:157-62 3. Nicholson G, Pereira AC, Hall GM. Parkinsons disease and Anaesthesia. British Journal of Anaesthesia 2002;89:904-16

Created: June 2015 Review: June 2017 Authors: Dr Siobhane Holden, Mrs Jenny Oakley and Dr Stephen Gilligan

Appendix A

1. Patients on levodopa preparations Current Levodopa Rotigotine patch Regime Some patients may take controlled Madopar or release (CR) levodopa. Sinemet 62.5mg BD 2mg / 24 hrs 62.5mg TDS 4mg / 24hrs 100mg is equivalent to a 2mg / 24 62.5mg QDS 6mg / 24 hrs hrs patch, therefore if a patient is 125mg TDS 8mg / 24 hrs 125mg QDS 10 mg / 24 hrs taking a controlled release 187.5mg TDS 12 mg / 24 hrs preparation increase the patch dose 187.5mg QDS 16 mg / 24 hrs by 2mg in 24 hrs. 250mg TDS 16 mg / 24 hrs 250mg QDS 16 mg / 24 hrs E.g. A patient takes 62.5mg Stalevo Rotigotine //Levodopa patch Madopar TDS and 100mg Madopar 50/12.5/200 mg TDS 6mg / 24 hrs CR at night the patch dose is 6mg / 100/25/200 mg TDS 10mg / 24 24 hrs hrs 100/25/200 mg QDS 14mg / 24 hrs 150/37.5/200 mg TDS 16mg / 24 hrs 200/50/200 TDS 16mg / 24 hrs

2. Patients on dopamine Rotigotine patch 0.125mg TDS 2mg / 24 hrs 0.25mg TDS 4mg / 24 hrs  If the calculated dose is above 0.5mg TDS 6mg / 24 hrs 16mg consult a specialist as soon 0.75mg TDS 8mg / 24 hrs as possible regarding 1mg TDS 10-12mg / 24 hrs administration of 1.25mg TDS 14mg / 24 hrs 1.5mg TDS 16mg / 24 hrs  Prescribe as a 24 hour patch Rotigotine patch 1mg TDS 4mg / 24 hrs  Do not cut patches 2mg TDS 6mg / 24 hrs

3mg TDS 8mg / 24 hrs 4mg TDS 10-12mg / 24 hrs  Available as 2mg/4mg/6mg/8mg 6mg TDS 14mg / 24 hrs (can use more than one patch) 8mg TDS 16mg / 24 hrs Ropinirole XL Rotigotine patch  Adjust dose based on symptoms 4 mg/day 4mg / 24 hrs - If stiffness/slowness increase 6 mg/day 6mg / 24 hrs dose and review 8 mg/day 8mg / 24 hrs 12 mg/day 10-12mg / 24 hrs - If / 16 mg/day 14mg / 24 hrs decrease dose and review 24 mg/day 16mg / 24 hrs 3. For patients on a combination of the above medications or their current medication is not listed refer to Appendix B 4. Contact movement disorder specialist as soon as possible for ongoing management Created: June 2015 Review: June 2017 Authors: Dr Siobhane Holden, Mrs Jenny Oakley and Dr Stephen Gilligan

Appendix B

To calculate dose for rotigotine patch

Current levodopa equivalent dose = ( A + B ) x 0.55 = ___ mg Rotigotine patch = levodopa equivalent dose x 0.05 = ___ mg

Therefore dose for rotigotine patch =

( A + B ) x 0.0275 = __ mg

A B Total daily levodopa dose (mg) Total daily dopamine (mg) If modified release multiply by 0.75 If on pramipexole// If on COMT inhibitor multiply by 1.3 multiply by 100 X 0.0275 = __ mg If both multiply by 0.91 + If on ropinirole/rotigotine multiply by 20 If on apomorphine/ multiply by 10 = _____ mg = _____ mg

 Round to the nearest 2mg up to a maximum of 16mg  If the calculated dose is above 16mg consult a specialist as soon as possible regarding administration of apomorphine  Prescribe as a 24 hour patch  Do not cut patches  Available as 2mg/4mg/6mg/8mg (can use more than one patch)  Adjust dose based on symptoms o If stiffness/slowness increase dose and review o If confusion/hallucinations decrease dose and review

Contact movement disorder specialist as soon as possible for ongoing management

Created: June 2015 Review: June 2017 Authors: Dr Siobhane Holden, Mrs Jenny Oakley and Dr Stephen Gilligan

Appendix C Administration of Parkinson’s medication in patients with feeding tubes Preparation Formulation Directions for administering via feeding tube Dispersible Continue with current formulation, dose tablets and frequency Convert to dispersible tablets – Reduce dose by approximately 30% Co-beneldopa Modified

(Madopar) release tablets FREQUENCY will require amendment as dispersible tablets are shorter acting Convert to dispersible tablets Capsules Continue with same dose and frequency Tablets (standard Tablets will disperse in water release) Co-careldopa Convert to dispersible tablets – Reduce (Sinemet) dose by approximately 30% Modified

release tablets FREQUENCY will require amendment as dispersible tablets are shorter acting Tablets (standard Tablets will disperse in water Pramipexole release) Modified Convert to standard release tablets which release tablets will disperse in water Tablets (standard Tablets will disperse in water release) Ropinirole Convert to standard release tablets which Modified will disperse in water. Total daily dose release tablets must be given as a TDS regimen Crush and disperse in water

Stalevo Tablets Consider changing to individual components Cabergoline Tablets Crush and disperse in water Place tablet in barrel of syringe and allow to Entacapone Tablets disperse – do not crush as powder will stain clothing Selegeline Tablets Tablets will disperse in water Capsules Open capsules and dissolve in water Tablets Crush and disperse in water

Created: June 2015 Review: June 2017 Authors: Dr Siobhane Holden, Mrs Jenny Oakley and Dr Stephen Gilligan