Management of Patients with Parkinson's Disease Who Are Nil By
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MANAGEMENT OF PATIENTS WITH PARKINSON’S DISEASE WHO ARE NIL BY MOUTH OR WITH A COMPROMISED SWALLOW Author: Gordon W Duncan Status: Approved Authorised by: Clinical Policy Group Version: 1.0 Review date: July 2018 Date of authorisation: July 2015 Date added to Intranet: Sept 2015 Contents Contents .......................................................................................................... 1 Introduction ...................................................................................................... 2 A. When a patient with PD is admitted to hospital ...................................... 3 B. Patients with swallowing problems ......................................................... 4 C. The acutely confused patient with PD .................................................... 7 D. Nausea and vomiting in patients with PD ............................................... 7 E. Surgery and patients with PD ................................................................. 8 Appendix 1. Contact details for the NHS Lothian Parkinson’s disease team .. 9 Acknowledgements .......................................................................................... 9 1 Introduction This document outlines the principles of management of patients with Parkinson’s disease (PD) who have been admitted to an acute hospital in NHS Lothian and particularly those who have a compromised swallow or are nil by mouth (NBM). It is crucial that patients with PD always receive their PD medication on time even when they are unable to swallow. The purpose of this guidance is to describe how this is best achieved. Failure to administer PD medication can lead to swallowing problems and complications such as aspiration pneumonia, falls and confusion leading to patient distress and increased length of stay. The most severe, but very rare, complication is the Parkinsonism- hyperpyrexia syndrome; clinically it is similar to the neuroleptic malignant syndrome. NHS Lothian PD Services We provide a co-ordinated PD service run by nurse specialists and consultants. Please call the PDNS hotline (0131 465 9156) as the first point of contact, between 0900 and 1700, Monday to Friday. Our clinic letters are on TRAK and SCI Store. Please see the table of contacts in Appendix 1. 2 A. When a patient with PD is admitted to hospital 1. Obtain an accurate drug history a. Patient, carer, emergency care summary (ECS), GP or recent clinic letter on TRAK. b. Medication name, formulation, dose, timing and route of administration. 2. Prescribe usual medication at usual time a. Do not stop PD medications. b. Medication should be prescribed at the same time as taken at home; this may be different to the ward drug-round times. This must be emphasised to all staff caring for the patient. 3. Obtain PD medication as soon as possible, some of which may not be routinely stocked by the wards. a. Use the patient’s own supply whenever possible. b. Do not record as “3” / unavailable on the drug chart. c. All medications are available from the pharmacy during opening hours. d. Contact your ward pharmacist to obtain supplies if needed urgently. e. Out of hours, supplies are located on other wards or in pharmacy and can be obtained by contacting bleep 8100. 4. If a patient is admitted who is receiving Apomorphine, this should be continued and advice obtained from the PDNS team (0131 465 9156), the patient’s usual consultant or the ApoGo Helpline (0844 880 1327). Do not commence Apomorphine on a previously Apomorphine naïve patient. Parkinson’s disease medications Table 1. Parkinson’s disease medications used in NHS Lothian Levodopa Formulations Co-beneldopa Co-careldopa Levodopa/carbidopa/ (Madopar) (Sinemet/Sinemet CR) entacapone (Stalevo) Dopamine Agonists Ropinirole Pramipexole Rotigotine Apomorphine (Requip/Requip (Mirapexin/Mirapexin (Neupro) XL) PR) Other PD Medications (these may be safely omitted in a patient who is NBM) Selegiline Rasagiline Amantadine Entacapone Tolcapone (Zelapar) (Azilect) (Comtess) (Eldepryl) Note. Refer to the BNF for the details of composition of PD medications. 3 B. Patients with swallowing problems Swallowing problems should be assessed and managed according to NHS Lothian guidance available on the intranet. http://intranet.lothian.scot.nhs.uk/NHSLothian/Healthcare/A- Z/Stroke/Introduction/swallow%20screen%20V5_Aug%202014.pdf Obtain an urgent assessment by the SALT team for patients who are unable to swallow or are nil by mouth (NBM). It is essential that patients receive their standard PD medication or an appropriate alternative medication when they require it. This may require the placement of a nasogastric (NG) tube for medication administration or, if appropriate, a Rotigotine transdermal patch may be prescribed. Medications which may be safely omitted are Entacapone, Selegiline, Rasagiline and Amantadine. Patients with PD dementia or pre-existing neuropsychiatric disturbances are at high risk of delirium and should be considered for dispersible Madopar orally or via the NG route in the first instance. Patients unable to swallow and taking Levodopa medications only If the patient has an NG tube in place, convert to an equivalent dose of Madopar 50/12.5 dispersible tablets according to Table 2. Controlled Release (CR) preparations contain the same amount of Levodopa as the immediate release preparations and the conversion to Madopar dispersible tablets is the same. For Stalevo 75, Stalevo 125 and Stalevo 175 formulations there is not a direct equivalent dose conversion to Madopar; therefore prescribe the suggested doses shown in table 2. 4 Table 2. Levodopa formulations and conversion equivalents for use with NG tube Usual Levodopa regime Equivalent prescription of dispersible tablets Madopar 50/12.5 1 cap of Madopar 50/12.5 TDS 1 x dispersible tab Madopar 50/12.5 TDS 1 cap of Madopar 100/25 TDS 2 x dispersible tab Madopar 50/12.5 TDS 1 cap of Madopar 100/25 QDS 2 x dispersible tab Madopar 50/12.5 QDS 1 tab of Sinemet 50/12.5 TDS 1 x dispersible tab Madopar 50/12.5 TDS 1 tab of Sinemet 100/25 TDS 2 x dispersible tab Madopar 50/12.5 TDS 1 tab of Sinemet 100/25 QDS 2 x dispersible tab Madopar 50/12.5 TDS 1 tab of Stalevo 50 QDS 1 x dispersible tab Madopar 50/12.5 QDS 1 tab of Stalevo 75 QDS 1 x dispersible tab Madopar 50/12.5 QDS 1 tab of Stalevo 100 QDS 2 x dispersible tab Madopar 50/12.5 QDS 1 tab of Stalevo 125 QDS 2 x dispersible tab Madopar 50/12.5 QDS 1 tab of Stalevo 150 QDS 3 x dispersible tab Madopar 50/12.5 QDS 1 tab of Stalevo 175 QDS 3 x dispersible tab Madopar 50/12.5 QDS 1 tab of Stalevo 200 QDS 4 x dispersible tab Madopar 50/12.5 TDS If the patient is only taking a Levodopa formulation and the NG route is not available a. A Rotigotine transdermal patch may be prescribed. See conversion equivalent in Table 3 below. The starting dose of Rotigotine should be no higher than 8mg/24 hours for older or frail patients. b. The response should be assessed every 24 hours and titrated according to patient condition. The maximum daily dose for Rotigotine is 16mg/24 hours. c. Patches are available in 2mg, 4mg and 8mg strengths. Do not cut patches to achieve correct dose. d. Patch site should be rotated and not applied to same site for 14 days to avoid skin irritation. Dopamine agonists may precipitate or worsen confusion or hallucinations, should this occur, please seek advice from a member of the PD Team. 5 Table 3. Rotigotine conversion table for patients on a Levodopa or Stalevo formulation only Usual Levodopa medication regime Rotigotine 1 tab of Madopar or Sinemet 50/12.5 BD 2mg/24 hr 1 tab of Madopar or Sinemet 50/12.5 TDS 4mg/24 hr 1 tab of Madopar or Sinemet 50/12.5 QDS 6mg/24 hr 1 tab of Madopar or Sinemet 100/25 TDS 8mg/24 hr 1 tab of Madopar or Sinemet 100/25 QDS 10 mg/24 hr 1 tab of Madopar or Sinemet 150/37.5 TDS 12mg/24 hr 1 tab of Madopar or Sinemet 150/37.5 QDS 16mg/24 hr 1 tab of Madopar or Sinemet 200/50 TDS 16mg/24 hr 1 tab of Madopar or Sinemet 200/50 QDS 16mg/24 hr Usual Stalevo regime Rotigotine 1 tab of Stalevo 50 TDS 6mg/24 hr 1 tab of Stalevo 100 TDS 10mg/24 hr 1 tab of Stalevo 100 QDS 12mg/24 hr 1 tab of Stalevo 150 TDS 14mg/24 hr 1 tab of Stalevo 200 TDS 16mg/24 hr 1 tab of Stalevo 200 QDS 16mg/24 hr Note. The starting dose of Rotigotine should be no higher than 8mg/24 hours for older or frail patients. If the patient is only taking a dopamine agonist medication Table 4 shows how crushed tablets may be given on a short term basis (i.e. first 48 hours) through an NG tube. Alternatively a Rotigotine patch may be applied and the appropriate dose conversions for Ropinirole and Pramipexole are shown in table 5 and table 6 respectively. Table 4. Dopamine agonist Advice Rotigotine (Neupro) Continue Maintain same dose, crush tablets* and mix Ropinirole (Requip) with water prior to administration Convert to standard dose Ropinirole and crush Ropinirole XL (Requip XL) as above* e.g. 18mg XL = 6mg TDS Pramipexole (Mirapexin) Maintain same dose, crush tablets* Pramipexole PR (Mirapexin Convert to standard does Pramipexole and PR) crush as above* Apomorphine Continue *Unlicensed use but accepted practice in this clinical situation. 6 Table 5. Rotigotine conversion table for patients taking Ropinirole Ropinirole Ropinirole XL Rotigotine 0.750mg TDS 2mg/day 2mg/24 hr 1mg TDS 4mg/day 4mg/24 hr 2mg TDS 6mg/day 6mg/24 hr 3mg TDS 8mg/day 8mg/24 hr 4mg TDS 12mg/day 10–12mg/24 hr 6mg TDS 16mg/day 14mg/24 hr 8mg TDS 24mg/day 16mg/24 hr Table 6. Rotigotine conversion table for patients taking Pramipexole* Pramipexole IR Pramipexole PR Rotigotine Salt Base Salt Base 0.125mg TDS 0.088mg TDS 0.375mg/day 0.26mg/day 2mg/24 hr 0.25mg TDS 0.18mg TDS 0.75mg/day 0.52mg/day 4mg/24 hr 0.5mg TDS 0.35mg TDS 1.5mg/day 1.05mg/day 6mg/24 hr 0.75mg TDS 0.53mg TDS 2.25mg/day 1.57mg/day 8mg/24 hr 1mg TDS 0.7mg TDS 3mg/day 2.1mg/day 10–12mg/24 hr 1.25mg TDS 0.88mg TDS 3.75mg/day 2.62mg/day 14mg/24 hr 1.5mg TDS 1.05mg TDS 4.5mg/day 3.15mg/day 16mg/24 hr *Salt and base strengths may be specified.