Acute management of in-patient Parkinson s Disease patients

Transcription

1 Acute management of in-patient Parkinson s Disease patients Contents Pages Introduction and Admission advice 2 Nil by Mouth Guidance 3 5 Complex therapy advice (Apomorphine, DBS, Duodopa) 6 Surgical peri-operative advice 7 Contacts/Directory 7 Approved by the Managed Services Drug and Therapeutics Committee August (Review date August 2019) Page 1

2 Introduction Medication is crucial in optimal management of Parkinson s. If medication is not given this can result in compromised swallow (increasing risk of aspiration), delirium, speech difficulties, immobility and hence more dependence. It can also lead to increased falls in a population at high risk of fractures. At worst they may develop a Neuroleptic Malignant Type Syndrome which can be fatal. People with Parkinson s are admitted to hospital for numerous reasons. Often these are unrelated to their Parkinson s but if not managed appropriately on admission this can lead to delayed recovery, delayed discharge and poor outcomes for patients and their families. This document has been devised to provide guidance to staff who are involved in the care of someone with Parkinson s admitted to hospital for whatever reason should the Parkinson s Specialist Team be unavailable. (e.g. weekend or out of hours) It should be highlighted that these guidelines provide advice to medical and nursing staff to ensure people with Parkinson s are managed appropriately on admission i.e. receive some antiparkinsonian medication until they can be seen by a member of the Parkinson s Team to provide specialist advice on complex medicines management. On admission: - ENSURE PATIENTS GET THE RIGHT MEDICATION AT THE RIGHT DOSE AT THE RIGHT TIME 1. Obtain accurate drug history as per medication reconciliation policy (see intranet link below) pdf Remember: - Medication name (brand or generic name) -Preparation e.g. standard, dispersible, controlled release -Usual timing of medication at home 2. Ensure patient is prescribed medication at correct times i.e. times taken at home NOT usual drug round times. Apply Parkinson s medication Alert sticker to front of the Drug chart 3. Obtain medication as soon as possible. If the patient has brought in their own medication please use these as outlined in the NHS Fife Safe Use of Medicines Policy (intranet link below) 0Use%20of%20Medicines%20Policy%20and%20Procedures%20Version%202%20Aug%2017.pdf 4. DO NOT STOP PARKINSON S MEDICATIONS 5. DO NOT PRESCRIBE MEDICATION WHICH CAN WORSEN PARKINSON S SYMPTOMS, i.e. metoclopramide, haloperidol, prochlorperazine, cyclizine. If patient requires anti-emetics, please use domperidone either orally or as suppository if swallow compromised. Ondansetron can also be used (off label). 6. If on s/c apomorphine and concern regarding management please contact Parkinson s Team ASAP or Apo-go Helpline: Approved by the Managed Services Drug and Therapeutics Committee August (Review date August 2019) Page 2

3 Parkinson s patient admitted with a compromised swallow or NBM Contact Parkinson s disease team urgently to discuss (Ext or see directory). Out of hours or unable to contact them then please follow flow diagram Is the patient able to swallow liquids safely? Yes No (Convert to dispersible preparations) Go to table 1 Consider URGENT NG tube insertion providing the following:- Successful insertion 1. NG will be inserted, secured and position clarified within 4 hours 2. NG will be tolerated by the patient 3. No contraindication to NG insertion 4. No bowel obstruction or under lying pathology likely to impair oral medication absorption NG not suitable Convert the patient s levodopa dose to equivalent rotigotine patch dose (Go to table 2). If the patient is on a dopamine agonist also convert to the equivalent rotigotine dose (go to table 3). This will estimate the equivalent patch dose to start. The maximum dose of rotigotine patch which can be prescribed is 16mg od (THIS MUST NOT BE EXCEEDED) For complex non oral therapies see Apomorphine, Duodopa and DBS sections Approved by the Managed Services Drug and Therapeutics Committee August (Review date August 2019) Page 3

4 Table 1 (patients able to swallow liquids or successfully sited NG) Convert each drug the patient is on for their Parkinson s disease as described in the table below DRUG Preparation What to do Madopar (co-beneldopa) / sinemet (co-careldopa) Immediate release or dispersible Controlled release Convert to madopar dispersible tablets at the same dose. (e.g. sinemet 100/25 qds would covert to madopar 100/25 qds). Maintain the same timings and dose. Convert to madopar dispersible tablets at the same dose. (e.g. sinemet CR 100/25 qds would covert to madopar 100/25 qds). Maintain the same timings and dose. Rotigotine patch Transdermal patch Prescribe transdermal patch at usual dose Ropinirole Immediate release / Modified release Pramipexole Immediate release / Modified release Selegiline Rasagiline and Safinamide Entacapone and Opicapone Stalevo, Sastravi or Stanek (these are equivocal combination preparations containing cocareldopa and entacapone) Amantadine Convert to rotigotine patch see table 3 Convert to rotigotine patch see table 3 Convert to oro-dispersible tablets be aware that 10mg tablet is equivalent to 1.25mg or dispersible tablet Can be safely withheld till review by PD team Can be safely withheld till reviewed by PD team Clarify the levodopa quantity in each dose and convert to dispersible co-beneldopa (e.g. stalevo 150 has 150mg co-careldopa = disp. co-beneldopa 150/37.5mg) and dose at the same frequency and times til reviewed by PD team Can be safely withheld till review by PD team Approved by the Managed Services Drug and Therapeutics Committee August (Review date August 2019) Page 4

5 Table 2 - Converting levodopa preparations to rotigotine patch Warning:- When starting a dopamine agonist naive patient on a rotigotine patch, specialist opinion needs to be sought as soon as possible after commencement. Look out for side effects such as vomiting, skin reactions, hypotension, hallucinations and increased confusion. Caution in patients with delirium and dementia. Maximum dose is 16mg/24hours and any other regimes exceeding the levodopa regimes below should be started on 16mg once daily. Current levodopa regime Rotigotine patch equivalent Madopar or Sinemet 62.5 mg BD 2 mg /24 hours Madopar or Sinemet 62.5 mg TDS 4mg /24 hours Madopar or Sinemet 62.5 mg QDS 6 mg /24 hours Madopar or Sinemet 125 mg TDS 8 mg /24 hours Madopar or Sinemet 125 mg QDS 10 mg /24 hours Madopar or Sinemet mg TDS 12 mg /24 hours Madopar or Sinemet mg QDS Madopar or Sinemet 250 mg TDS Stalevo or Stanek 50/12.5/200 TDS 6 mg /24 hours Stalevo or Stanek 100/25/200 TDS 10 mg /24 hours Stalevo or Stanek 100/25/200 QDS 14 mg /24 hours Stalevo or Stanek 150/37.5/200 TDS Stalevo or Stanek 200/50/200 TDS (Stalevo and Stanek are combination therapy containing co-careldopa and entacapone) NB:- 100mg levodopa CR is approximately equivalent to 2mg/24hr rotigotine, therefore if patient is on CR levodopa preparations please increase equivalent by 2mg/24 hr e.g. if patient takes Madopar 62.5mg TDS and Madopar 100/25mg CR nocte: equivalent Rotigotine dose = 6mg/24hr Table 3 - Conversion of oral dopamine agonist to rotigotine patch *Pramipexole (values in SALT content) *Pramipexole M/R (values in SALT content) Ropinirole Standard release (Requip) Ropinirole Modified Release (Requip XL) Rotigotine Patch equivalent mg TDS 375 micrograms 0.75mg TDS 2mg/day 2 mg/24 hours 0.25 mg TDS 750 micrograms 1mg TDS 4 mg/day 4 mg/24 hours 0.5mg TDS 1.5 mg 2 mg TDS 6 mg/day 6 mg/24 hours 0.75 mg TDS 2.25 mg 3 mg TDS 8 mg/day 8 mg/24 hours 1 mg TDS 3 mg 4 mg TDS 12 mg/day 12mg/24 hours 1.25 mg TDS 3.75mg 6 mg TDS 16 mg/day 14 mg/24 hours 1.5 mg TDS 4.5 mg 8 mg TDS 24 mg/day 16 mg/24 hours *Be aware that Pramipexole dosing can be described as Salt or Base values. Ensure that you know the correct strength and dosing and that this corresponds to the Salt value when converting using table 3 (see BNF pramipexole dosing conversion link below). Approved by the Managed Services Drug and Therapeutics Committee August (Review date August 2019) Page 5

6 Complex Therapies (Apomorphine, DBS, Duodopa) All patients admitted with subcutaneous apomorphine, Deep brain stimulation device or intestinal duodopa need urgent highlighting to the Parkinson s disease nurse specialists (PDNS) ext If out of hours then see information below:- Subcutaneous Apomorphine If on subcutaneous Apomorphine pens as required then these should be prescribed as per the patient s usual PD medication prescription and if in doubt then withheld till review by PDNS and ensure the other medications prescribed accurately. If on an ApoGo infusion pump, continue usual infusion of apomorphine (do not adjust), the patient and their carers will be trained in the use and maintenance of these pumps. In the event of the patient lacking capacity and there is no support from a carer then the helpline below is available to guide in managing. APO-go Technical Helpline (24 Hours a day, 365 days a year) DBS (Deep Brain Stimulation) Inform PDNS of admission as soon as possible. If any concerns with respect to DBS functioning out of hours then discuss with on-call neurology. Ensure patients receive their other regular PD medication. Duodopa (PEJ intestinal levodopa gel infusion) Inform PDNS of admission as soon as possible. The patient and their carers will be trained in the use and maintenance of these pumps. Continue patient s usual infusion regime. If any concerns with respect to functioning of the pump out of hours then discuss with on-call neurology. Ensure patients receive their other regular PD medication Approved by the Managed Services Drug and Therapeutics Committee August (Review date August 2019) Page 6

7 Peri - operative advice Operating list: Place first on the list if possible. Review the patients dosing regimen. If the timing of PD medication is going to clash with surgery the regimen may need to be altered. Please contact PDNS for advice regarding alteration of timings. Review the patient s regular medication prior to surgery. Ensure morning doses of all PD medications are prescribed. Clearly mark the drug chart that they must be given prior to surgery. Operating or anaesthetic team to discuss with PDNS if any concern. If the total duration of surgery or NBM status is going to be longer than 6 hours please contact PDNS. Rotigotine transdermal patch may need to be considered for this period. Deep Brain Stimulation: Ensure surgeon is aware of this as diathermy will be contraindicated. Contacts Parkinson s Disease Nurse Specialists Lynda Kearney and Gillian Aldrich Ext Consultants Ewan Tevendale Ext Nicola Chapman Ext Aylene Kelman Ext Sean McAuley Ext Martin Zeidler Ext Uwe Spelmeyer Ext Suzanne Burns Ext Approved by the Managed Services Drug and Therapeutics Committee August (Review date August 2019) Page 7