Management of Parkinson s Disease in Primary and Secondary care for patients with compromised swallow or those patients deemed Nil By Mouth. To aid the management and treatment of Parkinson s Patients with compromised swallow and those nil by mouth. AUTHORS: Alison Waldron (Acute Clinical Nurse Specialist in Parkinson s disease) Steven Shanu (Resident Pharmacist) Sarah Baig (Medicines Information/Neurology Directorate Pharmacist) Dr. Janine Barnes (Neurology Specialist Pharmacist) Dr. Shams Duja (Consultant in Elderly Care) Dr. Alistair Lewthwaite (Consultant Neurologist) Trudy Gaskin (Community Clinical Nurse Specialist in Parkinson s disease) VERSION CONTROL June 2014 1.0 This is a new document August 2014 Consultation with GPs (primary care) Dr Bowen, Dr Martin Consultation with consultants (secondary care) Dr Michael Dr Stellman Dr McGrath Dr Ijaola Dr Lewthwaite Dr Douglas Review of document version 1.1 December 2014 Version 1.1 Circulated to GP s PBP s DGNHSFT Consultants DGNHSFT Nurses Dudley CCG Dudley MBC NOC Project Support CCG Head of Commissioning
A translation service is available for this document. The Interpretation/Translation Policy, Guidance for Staff is located on the intranet under Trust-wide Policies. Contents Section Page Number 1 Introduction 3 2 Statement of Intent 3 3 Scope 3 4 Definitions 3 5 Duties & Responsibilities 3 6 Consequences of missing Parkinson s medicines 3 7.0 Parkinsons disease management in patients Secondary 4 care 7.1a) Patients with a compromised swallow or nil by mouth in 4 secondary care 7.1b) Hospital Surgery/NG patients (flow chart) 5 7.2 a) Community Palliative or end of life care patients (flow 5 chart) 8.0 Nasogastric administration of Levodopa and Dopamine 6-7 Agonist 9.0 Conversion table for Transdermal delivery 7 10.0 Drugs to avoid in Parkinson s Disease 7 11.0 Apomorphine Guidelines 7 12.0 Contact Details 8 13.0 References and Acknowledgements 8-9 Appendix 1 Common oral medicines used in Parkinson s Disease 10 Appendix 2 Commonly used drugs to avoid in Parkinson s Disease 11 Appendix 3 Conversion Algorithm 12 Appendix 4 Conversion charts 13 Appendix 5 Review and monitoring adherence to guideline 14
1. INTRODUCTION Clinical experience and audit has revealed that Parkinson s patients who are NBM or experience swallowing difficulties are experiencing lack of consistency in their prescribing of medication. This guideline aims to standardise treatment with respect to appropriate timings, doses and formulations for patients. 2. STATEMENT OF INTENT This document is designed to rationalise the prescribing in this patient group. There is an intention to meet individual patient needs and involve the patient and their family/carers in discussions and decisions about their medication and prescribing. 3. SCOPE The Nurse Practitioners of Parkinson s disease are responsible for the day to day management of Parkinson s disease patients both in hospital and in the community. The Pharmacists are responsible for specialist advice on specific medicines management and appropriate use of dose calculators. The consultant lead and medical team is responsible for the day to day medical management of Parkinson s disease The Area Clinical Effectiveness Committee will oversee the ratification of the guideline and appropriate review. 4. DEFINITIONS CK Creatinine Kinase MAO-B Monoamine Oxidase B inhibitor NBM Nil by mouth NG Naso Gastric NMS Neuroleptic Malignant Syndrome PD Parkinsons Disease L-Dopa Levo-Dopa COMT Catechol-o-methyl Transferase 5. DUTIES & RESPONSIBILITIES For patients managed in primary care please contact Trudy Gaskin (community Parkinson s specialist nurse) or Dr Janine Barnes (Neurology Specialist Pharmacist). For secondary care patients please contact Alison Waldron (Acute Clinical Nurse Specialist in Parkinson s disease), Dr Shams Duja (Consultant in Elderly Care) or Dr Alistair Lewthwaite (Consultant Neurologist). Review and update of this guideline will take place every 3 years. 3
6. CONSEQUENCES OF MISSING PARKINSONS DISEASE DRUGS Medication is crucial in optimal management of Parkinson s. If medication is not given it can result in the deterioration in patients symptoms, including reduced swallow, risk of aspiration, speech problems, increased risk of falls and increased dependence on nursing staff. At worst it may develop into Neuroleptic Malignant Syndrome. Neuroleptic Malignant Syndrome Rare Due to sudden withdrawal of PD medication Hyperthermia, muscle rigidity, altered level of consciousness, autonomic instability and elevated serum creatinine kinase (CK) level Onset within 1 to 9 days Major complications are respiratory, renal and cardiovascular failure Carries significant mortality People with Parkinson s are admitted to hospital for many reasons, very often unrelated to their Parkinson s. However if this is not managed appropriately on admission it can lead to delayed recovery, delayed discharge and poor outcomes for patients and their families. 7.0 PARKINSONS DISEASE MANAGEMENT IN PATIENTS SECONDARY CARE 7.1A) PATIENTS WITH A COMPROMISED SWALLOW OR NIL BY MOUTH IN SECONDARY CARE (Adapted from the NHS Tayside Administration of Medicine in the Peri-operative Period) Many people with Parkinson s present to surgical specialties for the management of conditions unrelated to their Parkinson s. The decision to discontinue, or accidentally omit, medication pre-operatively can cause severe harm including inability to swallow, speak or move increasing the risk of aspiration pneumonia, falls and fractures. It can precipitate an acute withdrawal syndrome similar to Neuroleptic Malignant Syndrome which can be fatal. If possible levodopa treatment should be continued throughout the peri-operative period. Selegiline and Rasagiline are both Monoamine oxidase inhibitors (MAO-B) and can interact with anaesthetic agents. The COMT inhibitors Entacapone, Tolcapone and Stalevo (entacapone plus levodopa) can all interact with adrenaline, isoprenaline and noradrenaline. The anaesthetist should be informed. If prolonged surgery expected or if oral route is going to be compromised post-operatively it may be worthwhile converting patient to rotigotine patch pre-operatively. Discuss with Parkinson s nurse specialist but in an emergency the online conversion calculator can be used to switch to rotigotine patch. See online calculator Patients and their family/carers will be kept informed and are actively encouraged to be involved in matters pertaining to medication changes and the management of their condition. Note: bedside swallow test used by nurses on some wards is designed for stroke patients only. Swallow problems are very common in Parkinson s, particularly during an intercurrent illness.
7.1 b) HOSPITAL FLOW CHART If you think the patient s swallow is compromised follow the following algorithm: Contact Acute Clinical Nurse Specialist for Parkinson s disease Bleep 5026 Refer to Speech and Language therapy via Soarian If unable to contact Parkinson s Disease Specialist Nurse, continue through flow chart Hospital contact Alison Waldron Bleep 5026 (Acute Clinical Nurse Specialist in Parkinson s disease) Can the patient tolerate an NG tube? YES Follow NG administration guidelines (section 8) NO Convert to Rotigotine patch see Hub 7.2 a) COMMUNITY - PALLIATIVE OR END OF LIFE CARE PATIENTS Does patient qualify to be transferred to hospital for NG/PEG administration of medications (As per palliative care guidelines) Dr. Janine Barnes (Neurology Specialist Pharmacist) Trudy Gaskin Community Clinical Nurse Specialist in Parkinson s disease Contactable via Dudley Rehabilitation Service 01384 323145 YES Transfer Patient to Hospital NO Convert To Rotigotine Transdermal patch Patients and their family/carers will be kept informed and are actively encouraged to be involved in matters pertaining to medication changes and the management of their condition. 5
PLEASE NOTE: CONVERSION BACK TO ORAL PD MEDICATION IS NOT ALWAYS APPROPRIATE. IF THIS IS REQUIRED THEN CONTACT THE RELEVANT PD NURSE (COMMUNITY OR HOSPITAL BASED) FOR ADVICE. 8. NASOGASTRIC ADMINISTRATION OF LEVODOPA AND DOPAMINE AGONIST On occasions it may be necessary to administer PD medications via an NG tube temporarily although these recommendations can be followed for long term enteral administration. Normal prescription Co-beneldopa (Madopar) Method of administration/alternative Madopar dispersible, same doses as tablets. CR formulations require a slight dose reduction. 12.5 mg benserazide + 50 mg levodopa. 25 mg benserazide + 100 mg levodopa. Tablets disperse in 10 ml of water within 2 minutes to give a cloudy white dispersion that flushes via an 8Fr NG tube without blockage Co-careldopa (Sinemet) Standard formulations disperse in water, alternatively convert to equivalent dose of dispersible co-beneldopa. Tablets disperse readily when placed in 10 ml of water to form a bright yellow dispersion that settles quickly but flushes via an 8Fr NG tube without blockage. Care must be taken to administer whole dose owing to the tendency for settlement to the bottom of the container/syringe. 2 CR formulations require a slight dose reduction. 1 Entacapone Stalevo (combination of co-beneldopa and entacapone) Resagiline Selegiline Sinemet (cocareldopa) Sinemet 62.5mg tablet Sinemet 110mg tablet Sinemet Plus 125mg tablet Sinemet 275mg tablet Half Sinemet CR 125mg tablet Sinemet CR 250mg tablet Madopar (Cobeneldopa) Madopar 62.5mg disp. tablet Madopar 125mg disp. tablet Madopar 125mg disp. tablet 2 x Madopar 125mg disp. tablet Convert to ordinary formulation dose Convert to ordinary formulation dose Disperses less easily Enteral tubes will need to be flushed well after use Give equivalent doses of co-beneldopa dispersible as above and entacapone as above.2 Contacted the manufacturer, unfortunately no information is available on crushing. Consider switch to selegiline if patient unable to swallow Zelapar ( melt (dissolves on the tongue) 1.25mg equivalent to 10mg selegiline If patient able to take buccal tablets, alternatively crush tablets. Syrup preparation 10mg/5ml (only for enteral tubes) 2
Amantadine Liquid available (50mg/5ml) for enteral tubes only Amantadine hydrochloride is freely soluble in water. 2 The capsules may be opened and mixed with water and administered immediately via an enteral feeding tube. 1,2 Ropinerole Ropinerole L Pramipexole Pramipexole PR (prolonged release) Maintain same doses Crush tablets. Tablets disintegrate rapidly when placed in 10 ml of water to give fine dispersion that flushes via an 8Fr NG tube without blockage. 1 Convert to standard ropinerole Crush as above Ropinirole Starter pack 1mg tds 2mg tds 3mg tds 4mg tds 6mg tds 8mg tds Controlled release Ropinirole (L) N/A 4mg/day 6mg/day 8mg/day 12mg/day 16mg/day 24mg/day Maintain same doses crush tablets and disperse in water 2 Convert to standard pramipexole Crush as above Pramipexole (salt content) 0.125mg tds 0.25mg tds 0.5mg tds 0.75mg tds 1mg tds 1.25mg tds 1.5mg tds Pramipexole (base content) 0.088mg tds 0.18mg tds 0.35mg tds 0.53mg tds 0.7mg tds 0.88mg tds 1.05mg tds 9. CONVERSION TO TRANSDERMAL DELIVERY (PATCH SYSTEM) VIA HUB 10. DRUGS TO AVOID IN PARKINSONS DISEASE For drugs to avoid in Parkinson s disease please refer to appendix 2 11. APOMORPHINE PRESCRIBING/DISPENSING Under no circumstances should this be initiated without involvement with a Parkinson s specialist. 7
11. a) HOSPITAL If a patient is admitted on apomorphine please contact the PD nurse specialist as soon as possible. If urgent advice is needed out of hours there is a 24 hour Apo-go helpline available on 0844 880 1327. Out of hours please contact the on-call pharmacist via switchboard. 11. b) COMMUNITY For any community queries regarding apomorphine please contact Trudy Gaskin or Janine Barnes via Dudley Rehabilitation Service (01384 323145) or If urgent advice is needed out of hours there is a 24 hour Apo-go helpline available on 0844 880 1327. 12. CONTACT DETAILS Alison Waldron (Acute Clinical Nurse Specialist in Parkinson s disease), Dudley Group NHS Foundation Trust. Bleep 5026 Trudy Gaskin (Community Clinical Nurse Specialist in Parkinson s disease) 01384 323145 / 0792 070 2109 Dr Janine Barnes (Neurology Specialist Pharmacist) 01384 323145/ 0782 593 2587 13. REFERENCES AND ACKNOWLEDGEMENTS 1. Smyth J, editor. The NEWT Guidelines for administration of medication to patients with enteral feeding tubes or swallowing difficulties. Print version, 2 nd edition published 2012. Online version updated more frequently, available at www.newtguidelines.com (subscription required). 2. Handbook of Drug Administration via Enteral Feeding Tubes. Accessed via www.medicinescomplete.com on 12 th March 2013. 3. Cabergoline vs Pergolide vs Pramipexole vs Ropinirole. Grosset et al. Movement Disorders2004;19 (11):1370-4 4. Ropinirole, Pramipexole, Cabergoline vs Rotigotine. Le Witt et al. Clinical Neuropharmacology2007; 30 (5): 256-65 5. Ropinirole vs Requip L. Summary of product Characteristics, Requip L. Electronic Medicines Compendium. 6. Algorithm for estimating parenteral doses of drugs for parkinson s Disease. Brennan K, Genever R. BMJ 2010;341 7. Acute management of PD patients with compromised swallow or NBM. Formulated by PDNS North west.
8. Acute management of Parkinson s patients. NHS Fife. 2011. 9. NHS Tayside guide to the administration of medicines in the peri-operative period June 2012 10. NHS Dudley Parkinson s disease prescribing guidelines for use in primary and secondary care. Access via: Parkinson s Disease Prescribing Guidelines for use in Primary and Secondary Care 9
Appendix 1 COMMON ORAL MEDICATIONS USED IN PARKINSON S DISEASE Type of Drug Drug Name How it Works Precautions Levodopa Co-careldopa Co-beneldopa Sinemet Madopar Dopamine Agonist Monoamine Oxidase type B (MAO-B) inhibitors COMT inhibitors Pramipexole Ropinerole Selegiline Rasagiline Entacapone Stalevo Anticholinergics Trihexyphendyl (Benzhexol) Glutamate Agonist Amantadine L-dopa is the precursor of dopamine. Can be used at all stages of the disease process. Works well on stiffness and Bradykinesia Stimulates post synaptic dopaminergic receptors Slows the metabolism of dopamine Blocks the metabolism of dopamine Blocks the action of acetylcholine (which breaks down dopamine) Enhances the release of dopamine. Anticholinergic properties Becomes less effective over time. Dyskinesia Drowsiness Hallucinations Postural Hypotension Nauses/vomiting Hallucinations Impulse Control Disorder Confusion Drug is a stimulant, therefore should be taken in the morning Will increase side effects of L-dopa Limited efficacy Neuro-psychiatric side effects Mild effect Short lived Insomnia
Appendix 2 COMMONLY USED DRUGS TO AVOID If patient already stabilised on therapy review and monitor Table highlighting drugs to avoid (and use) when treating hallucinations and nausea: Drug Chlorpromazine Treatment of Hallucinations /Confusion Treatment of Nausea / Vomiting Vigilance is required with the use of Fluphenazine Perphenazine Trifluoperazine Flupenthixol Haloperidol Quetiapine Clozapine (specialist initiation only) Metoclopramide Prochlorperazine Domperidone Cyclizine Ondansetron Antihistamines ¹ Antidepressants ¹ Antipsychotics ¹ Antihypertensives e.g Calcium Channel Blockers ¹ Key: x Not recommended Recommended ¹ Vigilance required 11
Appendix 3 CONVERSION ALGORITHM Algorithm for estimating equivalent levodopa dosages for Rotigotine patch This is the Parkinson s UK validated calculation tool for conversion of oral Parkinson s medications to transdermal patch. This has been incorporated into the online Rotigotine convertor. 1. Calculate Adjusted Levodopa Equivalent Daily Dose (LEDD): [(A) + (B)] x 0.55 = -------mg (A) Total adjusted daily levodopa dose. Total daily levadopa dose in mg (excluding benserazide or carbidopa). 0.7 (if MR/CR) or 1.3 (if on COMT inhibitor) or 0.91 (if MR/CR and on COMT inhibitor) = ------mg (B) Total adjusted daily dopamine agonist estimate levodopa equivalent dose Total daily dopamine agonist in mg 100 (if on pramipexole/ cabergoline/ pergolide 20 (if on ropinerole) 10 (if on bromocriptine/ apomorphine = ------mg (the above figures refer to each medications levodopa equivalent factor) 2. Calculate dosage for Rotigotine patch = Adjusted LEDD / 20 = ------mg Maximum Rotigotine dose of 8mg in 24hrs (for monotherapy) Maximum Rotigotine dose of 16mg in 24hrs (dual-therapy) Round to the nearest 2mg (max of 16mg) and prescribe as 24hr patch DO NOT CUT PATCH. Available as 1mg//2mg/3mg/4mg/6mg/8mg patches (can use more than one patch).
Appendix 4 CONVERSION CHARTS Conversion table for dopamine agonists Pramipexole (salt content) Pramipexole (base content) Ropinirole Controlled release Ropinirole Rotigotine patch 0.125mg tds 0.088mg tds Starter pack N/A 2mg/24 hrs 0.25mg tds 0.18mg tds 1mg tds 4mg/day 4mg/24hrs 0.5mg tds 0.35mg tds 2mg tds 6mg/day 6mg/24hrs 0.75mg tds 0.53mg tds 3mg tds 8mg/day 8mg/24hrs 1mg tds 0.7mg tds 4mg tds 12mg/day 10-12mg/24hrs 1.25mg tds 0.88mg tds 6mg tds 16mg/day 14mg/24hrs 1.5mg tds 1.05mg tds 8mg tds 24mg/day N/A Conversion table for levodopa Current levodopa regime (standard release) Co-beneldopa or co-careldopa 62.5 bd Co-beneldopa oe co-carel dopa 62.5 tds Co-beneldopa or co-careldopa 62.5 qds Co-beneldopa or co-careldopa 125 tds Co-beneldopa or co-careldopa 125 qds Rotigotine patch equivalent 2mg/24hrs 4mg/24hrs 6mg/24hrs 8mg/24hrs 10mg/24hrs Conversion table for Stalevo Current stalevo regime Rotigotine patch equivalent Dispersible co-beneldopa (May need to give smaller, more frequent dosing) 50/12.5/200 tds 6mg/24hrs 62.5mg qds 100/25/200 tds 10mg/24hrs 125mg qds 100/25/200 qds 14mg/24hrs 125 mg 5 times daily 150/37.5/200 tds 16mg/24hrs 125 mg 6 times daily 13
APPENDI 5 REVIEW AND MONITORING ADHERANCE TO GUIDELINES Lead Tool Frequency Reporting Arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Adherence to this guideline through actual and near miss incident reporting Inpatient Audit All Health Care Professionals Alison Waldron DATI Incident Reporting System Quarterly Audit Every 6 months Quarterly Aggregated Report of Incidents to the Clinical Quality Safety and Patient Experience Committee Report to Directorate Depending on Compliance, outcome and clinical or operational area Director Lead or Manager assigned. Depending on outcome Lead consultant will act Directorate Risk Management Groups