Guidelines for acute treatment of patients with Parkinson s disease including those who are nil by mouth
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1 Index No: MMG48 Guidelines for acute treatment of patients with Parkinson s disease including those who are nil by mouth Version: 2.0 Date ratified: November 2017 Ratified by: (Name of Committee) Name of originator/author, job title and department: Director Lead (Trust-wide policies) Associate Medical Director (local Policies): Clinical Management Team / Directorate Applicable to: Name of responsible committee for the policy: Medicines Management Committee Dr I Hubbard, Consultant Physician Medical Director Medicine Medicines Management Committee Date issued for publication: November 2017 Review date: August 2020 Expiry date: (Date 3 months following review date) Equality impact assessed by: (name, job title and department) Date impact assessed: CQC Fundamental Standards: November 2020 This clinical guideline does not involve direct engagement with staff, patients, carers, visitors, the public or others and therefore does not require an Impact Assessment in line with Procedure D10a Regulation 12: Safe Care and Treatment those who are nil by mouth. 1
2 CONTRIBUTION LIST Individuals involved in developing the document Name Dr Irene Hubbard Dr Samrat Roychowdhury Anthony Bartlett Designation Consultant Physician Consultant Physician Pharmacist Advanced Medicines Information & Informatics Members of Medicine CMT Clinical Governance Committee Circulated to the following individuals for consultation Name Dr Sunil Wimalaratna Designation Consultant Neurologist those who are nil by mouth. 2
3 Index No. MMG47 Guidelines for acute treatment of patients with Parkinson s disease including those who are nil by mouth Approval and Authorisation Completion of the following signature blocks signifies the review and approval of this process. Name Job Title Signature Date Local Committee approval (where applicable) Name of Committee Name of Chairperson Date of Approval Medicines Management Committee Mr R Lee November 2014 Change History Version Date Author Reason 1.0 November 2014 Dr I Hubbard New Guideline 2.0 November 2017 Dr I Hubbard Update at expiry. Impact Assessment This clinical guideline does not involve direct engagement with staff, patients, carers, visitors, the public or others and therefore does not require an Impact Assessment in line with Procedure D10a. A translation service is available for this guideline. The Interpretation/Translation Policy, Guidance for Staff (I55) is located on the library intranet under Trust wide policies. those who are nil by mouth. 3
4 CONTENTS 1.0 Introduction Patients admitted with Parkinson s Disease Initial acute management Managing patients unable to take regular PD medicines by mouth Medications that can be safely omitted if swallow is compromised Conversion from levodopa to rotigotine patches (no NGT available) Conversion from dopamine agonists to rotigotine patches (no NGT available) Conversion of levodopa products to dispersible Madopar for NG Tube or if other consistencies required due to SALT advice Management of other PD medicines where NGT available or if other consistencies required due to SALT advice Contacts for further advice Monitoring arrangements for compliance and effectiveness Plan for dissemination and implementation References 9 those who are nil by mouth. 4
5 1.0 Introduction If patients with Parkinson's disease (PD) do not get their medication on time, their ability to manage their symptoms may be lost, reducing quality of life and potentially delaying discharge from hospital. 2.0 Patients admitted with Parkinson s Disease Upon admission, it is crucial that patients with PD have a complete medication history taken and the inpatient prescription chart is written up promptly to avoid delayed or omitted doses. Medication regimens for PD do not necessarily match the timing of standard drug rounds on the wards. Prescriptions should be written to match the patient s usual regimen irrespective of these timings. It is crucial not to stop PD medication RISK OF NEUROLEPTIC MALIGNANT LIKE SYNDROME GET IT ON TIME: make sure the patient gets the right dose of PD medication at the right time for them 3.0 Initial acute management **Max dose domperidone 10mgTDS x 1 week. Check & repeat ECG. Avoid if prolonged QT syndrome or on other QT prolonging drugs. those who are nil by mouth. 5
6 4.0 Managing patients unable to take regular PD medicines by mouth 4.1 Medications that can be safely omitted if swallow is compromised: COMT Inhibitors: Entacapone, MAOI B Inhibitors: Selegiline (Zelapar), Rasagiline Amantadine 4.2 Conversion from levodopa to rotigotine patches (no NGT available) Each 100mg levodopa (Sinemet, Madopar, Stalevo) = approximately 2mg/24hrs rotigotine E.g. Sinemet 25/100 tds = 6mg rotigotine/24 hrs Madopar 200/50 qds = 16mg rotigotine/24 hrs The maximum dose of rotigotine is 16mg/24hrs. Patches are available in 2mg, 4mg, 6mg and 8mg strengths. The patches must not be cut to achieve correct dose Table 1: Conversion from oral levodopa to transdermal rotigotine Current Madopar /Sinemet regime* Rotigotine Patch to use / 24 Current Stalevo regime Rotigotine Patch to use / 24 hours hours 62.5mg BD 2mg 50/12.5/200 TDS 6mg 62.5mg TDS 4mg 100/25/200 TDS 10mg 62.5mg QDS 6mg 100/25/200 QDS 14mg 125mg TDS 8mg 150/37.5/200 TDS 16mg 125mg QDS 10mg 200/50/200 TDS 16mg 187.5mg TDS 187.5mg QDS 12mg 16mg those who are nil by mouth. 6
7 250mg TDS 16mg 250mg QDS 16mg *If also on modified release preparations CR at night then increase patch by 2mg per 100mg of CR dopamine. Note Madopar/Sinemet 125 CR = only 100mg of levodopa 4.3 Conversion from dopamine agonists to rotigotine patches (no NGT available) Table 2: Conversion from oral dopamine agonist to transdermal rotigotine Pramipexole (salt) Ropinirole (Requip) Ropinirole MR (Requip XL) Rotigotine Patch to use / 24 hours 0.125mg TDS Starter Pack N/A 2mg 0.25mg TDS 1mg TDS 4mg OD 4mg 0.5mg TDS 2mg TDS 6mg OD 6mg 0.75mg TDS 3mg TDS 8mg OD 8mg 1.0mg TDS 4mg TDS 12mg OD 10 12mg 1.25mg TDS 6mg TDS 16mg OD 14 16mg 1.5mg TDS 8mg TDS 24mg OD 14 16mg 4.4 Conversion of levodopa products to dispersible Madopar for NG Tube or if other consistencies required due to SALT advice Levodopa containing products may be converted to Madopar (co-beneldopa) dispersible tablets according to levodopa dose according to the following table. Brand name Preparations available Madopar Caps 62.5 Levodopa content 50mg levodopa mg benserazide Recommendation via NGT Madopar dispersible 12.5/50mg Madopar Caps mg levodopa + 25mg benserazide Madopar dispersible 25/100 Madopar Caps mg levodopa + 50mg benserazide Madopar dispersible 50/200 Madopar CR capsules mg levodopa + 25mg benserazide Madopar dispersible 25/100 Sinemet Tabs mg levodopa mg carbidopa Madopar dispersible 12.5/50mg Sinemet 110 Tabs 100mg levodopa + 10mg carbidopa Madopar dispersible 25/100 Sinemet Plus Tabs 25/ mg levodopa + 25mg carbidopa Madopar dispersible 25/100 Sinemet 275 Tabs 250mg levodopa + 25mg carbidopa Madopar dispersible 25/100 Half Sinemet CR tablets 25/ mg levodopa + 25mg carbidopa Madopar dispersible 25/100 Sinemet CR tabs 50/ mg levodopa + 50mg carbidopa Madopar dispersible 50/200 Caramet CR tablets 25/ mg levodopa + 25mg carbidopa Madopar dispersible 25/100 Caramet CR tablets 50/ mg levodopa + 50mg carbidopa Madopar dispersible 50/200 Stalevo 50/12.5/200* 50mg levodopa mg carbidopa + 200mg Entacapone Madopar dispersible 12.5/50 those who are nil by mouth. 7
8 Brand name Preparations available Levodopa content Recommendation via NGT Stalevo 75/18.75/200* 75mg levodopa mg carbidopa Madopar dispersible + 200mg Entacapone equivalent Stalevo 100/25/200* 100mg levodopa + 25mg carbidopa + 200mg Entacapone Madopar dispersible 25/100 Stalevo 125/31.25/200* 125mg levodopa mg carbidopa Madopar dispersible + 200mg Entacapone equivalent Stalevo 150/37.5/200* 150mg levodopa mg carbidopa Madopar dispersible 25/ mg Entacapone + Madopar Dispersible 12.5/50 Stalevo 175/43.75/200* 175mg levodopa mg carbidopa Madopar dispersible + 200mg Entacapone equivalent Stalevo 200/50/ mg levodopa + 50mg carbidopa + Madopar dispersible 50/ mg Entacapone Co-careldopa (generic) 10/100 10mg carbidopa + 100mg levodopa Madopar dispersible 25/100 Co-careldopa (generic) 25/100 25mg carbidopa + 100mg levodopa Madopar dispersible 25/100 Co-careldopa (generic) 25/250 25mg carbidopa + 250mg levodopa Madopar dispersible 50/200 *Stalevo tablets block the NGT and should be converted to Madopar dispersible If on Entacapone separately, this can be withheld and re-started later. Parkinsons UK has developed a guideline and calculator to help non-specialist clinicians to control PD patient symptoms in patients who cannot take their oral medications until specialists are available. This can be accessed via Management of other PD medicines where NGT available or if other consistencies required due to SALT advice Dopamine agonists Product Rotigotine Patch (Neupro ) 2mg up to 16mg Ropinirole Tablets (ReQuip ) TDS Ropinirole prolonged release (ReQuip XL ) OD* Pramipexole Tablets (Mirapexin ) TDS Pramipexole prolonged release tablets (Mirapexin PR ) Other Rasagiline tablets (Azilect ) Amantadine Capsules (Symmetrel ) Recommendation Continue patch Dissolve in water or convert to Rotigotine patch (see 4.3) Convert to rotigotine Patch (see 4.3) Dissolve in water or convert to Rotigotine patch (see 4.3) Convert to Rotigotine patch (see 4.3) Can be crushed or dissolved in water (or omit) Open and contents will dissolve in water (or omit) those who are nil by mouth. 8
9 Ropinirole & pramipexole tablets will dissolve in water. Controlled release formulations need converting to TDS regime. Easier to switch to rotigotine patch. Rasagiline tablets can be crushed and mixed with water. Amantadine capsules: open and contents will dissolve in water. 5.0 Contacts for further advice If further advice is needed contact either: Sharon Prendergast Parkinson s Nurse Specialist Dr Hubbard KGH Ext 2254 Dr Roychowdhury KGH Ext 2845 KGH Neurologist 6.0 Monitoring arrangements for compliance and effectiveness This guideline will be monitored by the Medicines Management Committee. This guideline will be reviewed by the Medicines Management Committee every three years and updated according to local requirements and national guidance. 7.0 Plan for dissemination and implementation Once approved this guideline will be available on the Trust Intranet. Staff will be informed via of the availability of the guidelines. 8.0 References Reid J. Acute management of Parkinson s patients. NHS Fyfe, Available from: 0Patients.pdf 2. Blochberger A., Jones S. Parkinson s disease: clinical features and diagnosis. Clinical Pharmacist 2011: Kearney D., Dunsmure L. Parkinson s Disease management Clinical Pharmacist 2011: Brennan K, Genever R: Algorithm for estimating parenteral doses of drugs for Parkinson s Disease, BMJ 2010: BNF 65, March Dopaminergic drugs used in Parkinson s disease those who are nil by mouth. 9
10 6. White B., Bradnam V. Handbook of drug administration via enteral feeding tubes. Pharmaceutical Press The Switch Guidelines Working Group, Guidelines for Dopamine Agonist Switching in Parkinson s Disease 8. LeWitt P et al. Overnight Switch from oral dopaminergic agonists to Transdermal Rotigotine patch in subjects with Parkinson s Disease. Clinical Neuropharmacol (5): East Sussex Healthcare NHS trust. Treatment of patients with Parkinson s disease who are NBM those who are nil by mouth. 10
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