Guideline for the Management of Parkinson s Disease Medication Trust Reference B26/2017

Transcription

1 Guideline for the Management of Parkinson s Disease Medication Trust Reference B26/ INTRUCTION 1.1 Guideline for the management of Parkinson s Disease Medication in adult patients presenting to UHL with Parkinson s Disease. This guideline applies to all staff within UHL who have responsibility for the management of Parkinson s Disease patients. 1.2 Parkinson s Disease (PD) is a complex, neurological condition which requires appropriate management and monitoring. Low et. Al (2015) demonstrated that PD patients have longer inpatient stays and higher hospital mortality rates than other groups of patients. Rapid recognition and appropriate management of PD specific hospital related problems may be delayed given the common lack of expertise in PD management of doctors, nurses, and allied healthcare professionals. Special considerations are required for patients who are admitted into hospital to ensure that symptom control is maintained during the inpatient period. Furthermore, inpatients with PD are at a higher risk of developing Delirium, Chest Infections (particularly Aspiration Pneumonia), Urinary Tract Infections (UTIs), Postural Hypotension and Falls. 1.3 Incidents involving PD medications are common in UHL. These are related to all stages involved in drug therapy; prescribing, administration and supply. Examples include patients designated Nil By Mouth (NBM) going for over a week without administration of any PD medication; patients receiving the incorrect dosage of their intended regimen throughout inpatient stay and usual regimens being altered due to apparent confusion caused by infections such as UTIs resulting in extended inpatient stay. 1.4 Patients with PD often have complex medication regimens with frequent doses throughout the day. Missed doses and inappropriate prescribing can cause deterioration in symptom control, resulting in acute akinesia (rigidity) and decreased mobility. Abrupt withdrawal of PD medications can be life threatening and can precipitate the onset of Neuroleptic Malignant Syndrome (NMS). Guideline for the Management of Parkinson s Disease Medication Page 1 of 13

2 2. GUIDELINE STANDARDS AND PROCEDURES 2.1 KEY RESPONSIBILITIES ON ADMISSION Healthcare Professional(s) HEALTHCARE PROFESSIONAL(S) DOCTOR OR OTHER PRESCRIBER KEY RESPONSIBILITIES Obtain an accurate drug history including timings, doses and strengths of regular and when required medications. Please also note the preparation of the medication e.g. whether it is dispersible or modified release etc. Prescribe medications promptly as per the patient s regular regimen in order to avoid delay in doses. Please note that the electronic prescribing system, EPMA will automatically put in preset times for dosage regimens. IT IS ESSENTIAL TO AMEND THE TIMINGS AS PER HOW THE PATIENT WAS USUALLY TAKING THE TABLETS Consider whether the patient s PD is well controlled. Treat each patient individually and adjust doses accordingly with input from the PD specialist team (See Section 2.15 Contact Details). o If increased stiffness / slowness INCREASE the dose and observe daily. o If increased confusion / hallucinations, DECREASE the dose and review daily. Consider whether the patient is able to self-administer their own medications whilst they are an inpatient. Please fill in a selfadministration assessment form and refer to the UHL selfadministration policy on insite. Administer medication at times prescribed and do not delay or omit doses. NURSING STAFF PLEASE NOTE ADMINISTRATION TIMES ARE UNLIKELY TO MATCH DRUG ROUNDS Consider use of timers as a reminder for administration. Please contact the PD specialist team for more information. PHARMACIST DOSES SHOULD NEVER BE OMITTED DUE TO UNAVAILABILITY SEE SECTION WHERE TO FIND PD MEDICATIONS. Prioritise medicines reconciliation in patients who have PD. Obtain an accurate drug history including timings, doses and strengths of regular and when required medications. Please also note the preparation of the medication e.g. whether it is dispersible or modified release etc. Check patient s own supply of medicine, ward stock availability and order promptly from pharmacy where necessary. Guideline for the Management of Parkinson s Disease Medication Page 2 of 13

3 2.1.2 Preferential Base Wards for PD Patients Where possible, patients should be transferred to wards which have experienced staff in PD management. At the LRI, these wards are 24 (Neurology), 36 (Geriatrics), 31 (Geriatrics) or 29 (Geriatrics) Where to Find Parkinson s Disease Medications Check whether the patient has brought their own medications to hospital. If not or are in a form which is unsuitable such as a dosette box, inform the ward pharmacist well before the next dose is due so that the drugs can be ordered promptly. In case of emergencies and out of hours, PD medication stock cupboards are available on ward 33, 34 and AMU. THERE SHOULD NEVER BE A SITUATION WHERE A DOSE IS MISSED DUE TO MEDICATION UNAVAILABILITY A DATIX should be completed in cases where doses are omitted so that a full investigation can be carried out. 2.2 DISEASE-DRUG INTERACTIONS Certain drugs are contraindicated in PD due to their action on Dopamine Receptors: DRUG Antipsychotics Antiemetics Anticholinergics EXAMPLES Haloperidol, Chlorpromazine, Promazine, Sulpiride, Risperidone Metoclopramide, Prochlorperazine (Domperidone or Cyclizine are preferred antiemetics for PD patients) Oxybutynin, Tolterodine and Tryciclic Antidepressants are best avoided in patients with PD related dementia as they may worsen cognitive function. 2.3 SWALLOWING DIFFICULTIES AND FEEDING TUBES Refer to Speech and Language Therapy (SALT) and to the PD specialist nurses where appropriate (See Section 2.15). NB. Correct posture can contribute to effective swallow. Parkinson s UK (2013) Review whether the gastrointestinal (GI) route is still available if so, please refer to the table (Section Drug Administration via Nasogastric (NG) tubes or Orally with Poor Swallow. Please note a NG tube may not always be appropriate e.g. if the patient is nearing end of life. If in doubt please contact a PD specialist. Consider prescribing dispersible Madopar 62.5mg when required for loss of symptom control alongside medication changes If the GI route is unavailable or inappropriate convert to Rotigotine patches (see Section 2.4.2). Never crush or split modified release preparations Guideline for the Management of Parkinson s Disease Medication Page 3 of 13

4 2.3.1 Drug Adminstration via NG tube or Orally with poor swallow (NEWT Guidelines 2015) DRUG FORMULATION RECOMMENDATION Dispersible Continue Capsules Capsules Convert to Dispersible (Same dose) Co-Beneldopa (Madopar ) Co-Carelodpa (Sinemet ) M/R tabs (Plain Release) Modified Release Convert to Dispersible (Same total daily dose). Inform PD nurse as may need to alter dose / frequency Continue. disperse in water Convert to standard release Co-Careldopa or Dispersible Madopar (Same total daily dose). Inform PD nurse as may need to alter dose / frequency Continue. disperse in water (Plain Pramipexole Release) Modified Release Convert to Plain Release. Divide total daily dose into regimen (Plain Continue. disperse in water Ropinorole Release) Modified Release Convert to plain release tablets. Divide total daily dose into regimen Rasagiline Continue. can be crushed and mixed in water Selegiline Continue. disperse in water Entacapone Continue. Take care if crushing as this produces red dust which may stain. Entacapone does not fully dissolve in water, so if giving via enteral feeding tube, the tube should be flushed well after administration. Carbergoline Continue. disperse in water Entacapone, Levodopa, Carbidopa (Stalevo ) Amantadine Capsules Continue, tablets will disperse in water. If for swallowing difficulties, consider mixing with honey, jam or orange juice they have a bitter taste. Continue. Capsules can be opened and dissolved in water. Medications which can be temporarily omitted in swallowing difficulties COMT Inhibitors: Entacapone, Tolcapone MAOB Inhibitors: Selegine / Rasagiline Guideline for the Management of Parkinson s Disease Medication Page 4 of 13

5 2.4 DOSAGE CONVERSION Online Dosage Conversions An online dosage conversion calculator developed by a team of PD specialists and pharmacists is available via the following link and is especially useful for patients with complex medication regimens Conversion To Rotigotine Patches Rotigotine patches are associated with side-effects including Postural Hypotension, Aggression, Impulse Control Disorders and other Dopaminergic Adverse Reactions such as Hallucinations, Dyskinesia and Peripheral Oedema. It is therefore important that the patient goes back to their usual oral medications once their swallowing function is restored. Please note that patches should NOT be cut. They are available as 2mg/4mg/6mg/8mg patches (More than one patch can be used to make up the total dose) Levodopa to Rotigotine Patches REGIMEN Madopar or Sinemet 62.5mg BD Madopar or Sinemet 62.5mg Madopar or Sinemet 62.5mg QDS Madopar or Sinemet 125mg Madopar or Sinemet 125mg QDS Madopar or Sinemet 187.5mg Madopar or Sinemet 187.5mg QDS Madopar or Sinemet 250mg Madopar or Sinemet 250mg QDS and above TOTAL DAILY DOSE OF LEVOPA 100mg 150mg 200mg 300mg 400mg 450mg 600mg 600mg >600mg RECOMMENDED DOSE OF ROTIGOTINE PATCH / 24HOURS 2mg 4mg 6mg 8mg 10mg 12mg 14mg 16mg 16mg (Max daily dose) and obtain specialist advice. Modified Release Preparations NB: 100mg Levodopa Modified Release is approximately equivalent to 2mg/24hr Rotigotine. For example, if a patient takes Sinemet 62.5mg BD and Half Sinemet CR 125mg NOCTE, this is equivalent to a Rotigotine patch dose of 4mg/24hours. Guideline for the Management of Parkinson s Disease Medication Page 5 of 13

6 Oral Dopamine Agonists to Rotigotine Patches PRAMIPEXOLE PLAIN RELEASE (SALT) 0.125mg 0.25mg 0.5mg 0.75mg 1mg 1.25mg 1.5mg PRAMIPEXOLE MIFIED RELEASE (SALT) 0.375mg 0.75mg 1.5mg 2.25mg 3.0mg 3.75mg 4.5mg ROPINOROLE STANDARD RELEASE 750micrograms 1mg 2mg 3mg 4mg 6mg 8mg ROPINOROLE MIFIED RELEASE N/A 4mg/day 6mg/day 8mg/day 12mg/day 18mg/day 24mg/day RECOMMENDED DOSE OF ROTIGOTINE PATCH / 24HOURS 2mg 4mg 6mg 8mg 12mg 16mg 16mg Max daily dose) and obtain specialist advice Conversion of Stalevo to Rotigotine Patches REGIMEN Stalevo 50/12.5/200 Stalevo 100/25/200 Stalevo 100/25/200 QDS Stalevo 150/37.5/200 Stalevo 200/50/200 RECOMMENDED DOSE OF ROTIGOTINE PATCH / 24HOURS 6mg 10mg 14mg 16mg 16mg Guideline for the Management of Parkinson s Disease Medication Page 6 of 13

7 2.5 APOMORPHINE Apomorphine is a Non-Ergot Dopamine Agonist which is delivered as an intermittent Subcutaneous Injection or a Pump. It must NOT be used via the Intravenous route On Admission Patients who are already on an established Apomorphine routine need to be continued at the prescribed dose and frequency of subcutaneous injection or rate of pump. Assess whether the patient administers Apomorphine themselves and whether they are capable of continuing this during their hospital stay Assess whether a relative or carer usually administers the Apomorphine and whether they are willing to continue to do so during the patient s hospital stay Determine whether the patient has brought in all the relevant Apomorphine equipment and medication with them with them e.g. APO-go pump, prefilled syringes, chrono syringes or connectors If patients are on the pump device determine their usual flow rate. A treatment free period is usually observed during sleeping hours, unless the patient has severe night time symptoms. Check the patients understanding and refer to recent neurology appointment letters Equipment Unavailable Check whether the patient has brought their own equipment in. If not, consider contacting the APO-go nurse advisor (See Section 2.15). Equipment can also be ordered from pharmacy via your Ward Pharmacist. For out of hours supply please contact the on-call pharmacist via switch board Initiation Apomorphine should be initiated by a specialist only. Patients treated with Apomorphine will usually need to start Domperidone at least two days prior to initiation of therapy. The Domperidone dose should be titrated to the lowest effective dose and discontinued as soon as possible. Before the decision to initiate Domperidone and Apomorphine treatment, risk factors for QT interval prolongation in the individual patient should be carefully assessed to ensure that the benefit outweighs the risk 1mg of Apomorphine HCl (0.1ml), may be injected subcutaneously during a hypokinetic or 'OFF' period and the patient is observed over 30 minutes for a motor response. If no response or an inadequate response is obtained, a second dose of 2 mg of Apomorphine HCl (0.2ml) is injected subcutaneously. Thereafter, increase dose at minimum of 40 minute intervals until a satisfactory result is obtained. The daily dose of Apomorphine as a subcutaneous injection varies widely between patients, typically within the range of 3mg-30mg, given as 1-10 injections and sometimes as many as 12 separate injections per day Patients who have shown a good 'ON' period response during the initiation stage of Apomorphine therapy, but whose overall control remains unsatisfactory using intermittent injections, or who require many and frequent injections (more than 10 Injections per day), may be commenced on or transferred to a continuous subcutaneous infusion by minipump and/or syringe driver. Intermittent bolus boosts are also usually needed on top of this. Please refer to the PD specialist team if initiation is required. Guideline for the Management of Parkinson s Disease Medication Page 7 of 13

8 2.6 SURGERY Ensure morning doses of PD medications are prescribed and given prior to the surgical procedure even if the patient is Nil By Mouth (NBM). Clearly mark the drug chart (Paper or EPMA) that they must be given prior to surgery. Prioritise patients with PD to the top of the surgery list If the patient s medication regimen will be interrupted by surgery or if the total duration of surgery is over 6 hours, please contact the specialist PD nurse for advice on adjustment to therapy. If the patient has had Deep Brain Stimulation (DBS), please ensure that the surgeon is aware prior to the surgical procedure. Anti-dopaminergic anti-emetics such as Metoclopramide should be avoided (see under Disease Drug Interactions) 2.7 ORTHOSTATIC HYPOTENSION Moderate orthostatic hypotension occurs in at least 20% of patients and may be related to the disease itself or PD medications. Non-pharmacological treatment includes increasing sodium intake, use of compression stockings, improved hydration, and raising the head of the bed on blocks. Review non-pd medications to see whether they can be stopped or the dose can be reduced, for example Diuretics, Antidepressants, Proton Pump Inhibitors, Anti-hypertensives, Antipsychotics and Anticholinergics. Please note that certain medications such as Antipsychotics should not be stopped suddenly please contact your Ward Pharmacist for advice. Consider asking the PD specialist team to review the PD medication to see whether Dopaminergic medication can be reduced. Consider a trial with Midodrine, taking into account contraindications and monitoring requirements. This can be switched to Fludrocortisone if Midodrine is contraindicated / not tolerated or ineffective. Do not continue pharmacological treatment if no benefit is observed 2.8 DEPRESSION Depression occurs in approximately 80% of all PD patients and can significantly affect quality of life. Depression may be under diagnosed in PD because the clinical features of depression overlap with motor features of PD (NICE 2006) Although non-pharmacological treatment such as counselling may be helpful, the mainstay treatment is medication as the pathological cause is thought to be organic in PD (Lyons 2011). Management of depression should be tailored to the individual, in particular, to their co-existing therapy. First line therapy is usually a Selective Serotonin Reuptake Inhibitor (SSRI) or Mirtazapine. 2.9 SLEEP DISTURBANCE Up to 98% of PD patients experience sleep disturbance which may be exacerbated during a patients inpatient stay. All patients should try to maintain good sleep hygiene and be counselled on the importance of keeping up a regular sleep schedule. Disturbed sleep could be a manifestation of OFF symptoms during the night and therefore evening Modified Release preparations can be considered with specialist input. Dopamine Agonists can cause insomnia and therefore these medications may require dose or timing adjustments. Clonazepam 250micrograms at night can be trialled for pharmacological management of insomnia in PD patients. Please review duration and efficacy regularly and consider stopping prior to discharge if appropriate. Guideline for the Management of Parkinson s Disease Medication Page 8 of 13

9 2.10 MANAGEMENT OF DELIRIUM OR PSYCHOSIS Refer to the UHL Trust Guidelines on Delirium for general management principals. Wherever possible, seek to reassure the patient using a calm manner. If the patient finds the presence of family comforting and reassuring, please contact them to come in, even if outside of conventional visiting hours. Look for underlying causes of Delirium or Psychosis such as Dehydration, Chest Sepsis, Hypoxia, Electrolyte Disturbance, Urinary Tract Infections and Constipation. Review the patient s non-pd medications first to see whether these are contributing to the patient s acute confusional state. For example, Anticholinergics such as Solifenacin, Tricyclic Antidepressants and Opiates can affect cognition. Consideration should be given to withdrawing or reducing PD medication that might have triggered Delirium or Psychosis (NICE 2017). Specialist input would be necessary from the PD team. Pharmacological interventions should be avoided wherever possible. If the patient is very agitated or aggressive consider using Quetiapine PO 12.5mg 25mg Daily to Twice Daily or Lorazepam 0.5mg-1mg (PO or IM) (Risk of Falls and Respiratory Depression with IM) Typical Antipsychotic drugs such as Haloperidol and Chlorpromazine should be avoided MANAGEMENT OF CONSTIPATION Encourage adequate fluid intake and mobilisation where appropriate. Review diet including fibre intake First line pharmacological treatment is an Osmotic Laxative such as Macrogol 1-2 sachets twice a day in combination with a stimulant laxative such as Senna 7.5mg 15mg at night DISCHARGE CONSIDERATIONS Clearly document any inpatient PD reviews or medication changes on the discharge letter A copy of the discharge letter should be sent to the patient s PD consultant as soon as possible ADVANCED CARE PLANNING Please refer to any advanced care planning that has taken place to ease decision making. This may be in the form of an Advanced Decision to Refuse Treatment, a Do Not Attempt Resuscitation (DNACPR) or the appointment of a Lasting Power of Attorney for Finance and/or health and social care END OF LIFE MEDICATIONS PD medications are critical, however are sometimes stopped in the last stage of life after clinical review. Please consider contacting a PD specialist for further input For symptom control, when required Midazolam can help with rigidity as well as agitiation. Levomepromazine should be avoided. Instead, consider use of Cyclizine for management of nausea and vomiting Guideline for the Management of Parkinson s Disease Medication Page 9 of 13

10 2.15 CONTACT Parkinson s Disease Specialist Nurses Elizabeth Hillman Mobile: Tel: Elizabeth.Hillman@uhl-tr.nhs.uk Kesha Obi Tel: Kesha.obi@uhl-tr.nhs.uk Neurology Outpatients Leicester General Hospital Consultant Neurologists Dr.Peter Critchley Tel Peter.Critchley@uhl-tr.nhs.uk Brain Injury Unit Leicester General Hospital Durban Simpson Tel: Mobile: Ben.Simpson@uhl-tr.nhs.uk Consultant in Acute Medicine Dr. Juan Cardenas Tel: Mobile: Juan.Cardenas@uhl-tr.nhs.uk Consultant Geriatricians Dr Victoria Haunton Tel: Mobile: Victoria.Haunton@uhl-tr.nhs.uk Dr. Glen Harper Tel: Glen.harper@uhl-tr.nhs.uk Dr. James Reid Tel: Mobile: james.reid@uhl-tr.nhs.uk Pharmacists David Kearney Lead CMG Pharmacist for Medicine Mobile: David.kearney@uhl-tr.nhs.uk Reena Raithatha Lead Pharmacist for Geriatrics Mobile: Reena.raithatha@uhl-tr.nhs.uk Guideline for the Management of Parkinson s Disease Medication Page 10 of 13

11 Anna Delf Lead Pharmacist for Geriatrics Mobile: Ward Pharmacist Cluster phone number specific to your ward Main Pharmacy: On-call pharmacist available 24 hours via switchboard Nurse Advisor in Apo-go Therapy Liz Carter Tel: Mobile: Education and Training No additional education or training is required 4. Monitoring Compliance What will be measured to monitor compliance Number of Parkinson s Disease medication doses omitted or delayed How will compliance be monitored Audit Monitoring Lead Dr Victoria Haunton Frequency Quarterly Reporting arrangements 5. Supporting References (maximum of 3) 1 Fife Guidelines (2013).Acute management of Parkinson s Version No. 2. Approved on behalf of NHS Fife by the Fife Area Drugs & Therapeutics Committee 2 National Institute for Health and Care Excellence (NICE) Parkinson s Disease in over 20s: diagnosis and management. CG35 June NEWT Gudielines, Administration of medication to patients with enteral feeding tubes or swallowing difficulties (2015) Copyright 2015 J Smyth, BetsiCadwaladr University Local Health Board (East). Available at 6. Key Words Parkinsons Disease, Co-Careldopa, Rotigotine, Apomorphine, Levodopa, Madopar, Sinemet CONTACT AND REVIEW DETAILS Guideline Lead (Name and Title) Executive Lead Dr Victoria Haunton (Geriatrician) Medical Director Contributing Authors Anna Delf (Lead Pharmacist for Geriatrics) Reena Raithatha (Lead Pharmacist for Geriatrics) Details of Changes made during review: July/August 2018 modified release statement and correction of Sinemet spelling Guideline for the Management of Parkinson s Disease Medication Page 11 of 13

12 7. Appendices APPENDIX 1 PARKINSON S DISEASE - QUICK REFERENCE GUIDE For more details, please refer to the full Parkinson s Disease (PD) Policy available on Insite Key Contact Details Parkinson s Disease Specialist Nurses Consultant Geriatrician Consultant Neurologist Elizabeth Hillman / Kesha Obi Elizabeth.Hillman@uhl-tr.nhs.uk Kesha.Obi@uhl-tr.nhs.uk Dr Victoria Haunton Victoria.Haunton@uhl-tr.nhs.uk Dr Ben Simpson Ben.Simpson@uhl-tr.nhs.uk Main Priorities Obtain an accurate drug history including timings, doses, formulations and strengths of all regular medications. Prescribe medications as per the patient s regular regimen. If the patient has not brought in sufficient medication, inform the ward pharmacist well before next dose is due so that the drugs can be ordered promptly. Administer at times prescribed (these are unlikely to correlate with routine drug rounds) Do not prescribe centrally acting dopamine antagonists e.g. antipsychotics such as Haloperidol, Metoclopramide etc. PD medications are CRITICAL and should NOT be omitted. Missed doses cause deterioration in symptom control and can be life threatening. Preferential Base Wards for PD Patients Ideally, patients should be transferred to wards which have experienced staff in PD management. At the LRI, these wards are 24 (neuro), 36 (geriatrics), 31 (geriatrics) or 29 (geriatrics). Where to Find PD Medications out of hours In case of emergencies and out of hours, PD medication stock cupboards are available on ward 33, 34 and AMU. If necessary, contact on-call pharmacist via switch Guideline for the Management of Parkinson s Disease Medication Page 12 of 13

13 Swallowing Difficulties and Feeding tubes Is the gastrointestinal (GI) route still available? NO Convert to Rotigotine patches. Please use online calculator or refer to full reference guide YES Can the patient swallow liquids? YES Refer to table opposite NO Consider urgent NG insertion and refer to table opposite. If the patient is likely to miss doses before the NG tube is place, please consider temporary switch to Rotigotine patches. DRUG FORMULATION RECOMMENDATION Dispersible Continue Co-Beneldopa Capsules (Madopar ) Capsules Convert to Dispersible (Same dose) Co-Carelodpa (Sinemet ) Pramipexole Ropinorole M/R M/R (Plain Release) M/R (Plain Release) M/R Convert to Dispersible (Same total daily dose). Inform PD nurse as may need to alter dose / frequency Continue. disperse in water Convert to standard release Co-Careldopa or Dispersible Madopar (Same total daily dose). Inform PD nurse as may need to alter dose / frequency Continue. disperse in water Convert to plain release tablets. Divide total daily dose into regimen Continue. disperse in water Convert to plain release tablets. Divide total daily dose into regimen Rasagiline Continue. disperse in water Selegiline Continue. disperse in water Entacapone Continue. Take care if crushing as this produces red dust which may stain. Entacapone does not fully dissolve in water, so if giving via enteral feeding tube, the tube should be flushed well after administration. Entacapone, Levodopa, Carbidopa (Stalevo ) Continue, tablets will disperse in water. If for swallowing difficulties, consider mixing with honey, jam or orange juice they have a bitter taste. Guideline for the Management of Parkinson s Disease Medication Page 13 of 13