1. INTRODUCTION
Parkinson’s disease is the second most common chronic neurodegenerative condition affecting especially people above the age of sixty. It is characterised by slowness of movement, muscle rigidity, tremor and postural instability. Although the motor features are predominantly used for the diagnosis, the disease is now regarded as a neurodegenerative and neuropsychiatric syndrome with multitude of motor and non- motor symptoms. The gastro intestinal tract is one of the first organs to be affected in Parkinson’s disease. Constipation and olfactory dysfunctions can occur many years before the motor signs appear.
A degree of dysphagia is universal in Parkinson’s disease but causes no problem at the early stages of the disease. However, this tends to get worse as the disease progresses. It is not uncommon for Parkinson’s patients to experience worsened swallowing during an acute illness. An alternative treatment regimen is often necessary in such circumstance depending on whether the patients are on a dysphagic diet, nil by mouth or on nasogastric feeding.
This guideline sets out the principles of managing the dysphagic Parkinson patient in an acute setting. This will ensure that Parkinson’s patients presenting with dysphagia will receive an appropriate alternative regimen and avoidance of complications of acute withdrawal of essential Parkinson’s medicines.
Parkinson’s patients presenting with swallowing difficulties are usually in the advanced stage of the disease and often have other comorbidities. Effective management of dysphagic Parkinson’s patients requires a multidisciplinary approach to reduce the associated morbidity and mortality and the length of hospital stay.
2. SCOPE OF DOCUMENT
This clinical document applies to:
Staff group(s)
Foundation Trust (KMH, NH, MCH) caring for and treating adult patients. Patient group(s)
• Adult patients 18 and above
Exclusions
• Paediatrics under the age of 18
Parkinson’s disease is the second most common chronic neurodegenerative condition affecting especially people above the age of sixty. It is characterised by slowness of movement, muscle rigidity, tremor and postural instability. Although the motor features are predominantly used for the diagnosis, the disease is now regarded as a neurodegenerative and neuropsychiatric syndrome with multitude of motor and non- motor symptoms. The gastro intestinal tract is one of the first organs to be affected in Parkinson’s disease. Constipation and olfactory dysfunctions can occur many years before the motor signs appear.
A degree of dysphagia is universal in Parkinson’s disease but causes no problem at the early stages of the disease. However, this tends to get worse as the disease progresses. It is not uncommon for Parkinson’s patients to experience worsened swallowing during an acute illness. An alternative treatment regimen is often necessary in such circumstance depending on whether the patients are on a dysphagic diet, nil by mouth or on nasogastric feeding.
This guideline sets out the principles of managing the dysphagic Parkinson patient in an acute setting. This will ensure that Parkinson’s patients presenting with dysphagia will receive an appropriate alternative regimen and avoidance of complications of acute withdrawal of essential Parkinson’s medicines.
Parkinson’s patients presenting with swallowing difficulties are usually in the advanced stage of the disease and often have other comorbidities. Effective management of dysphagic Parkinson’s patients requires a multidisciplinary approach to reduce the associated morbidity and mortality and the length of hospital stay.
2. SCOPE OF DOCUMENT
This clinical document applies to:
Staff group(s)
-
Trust’s Parkinson’s Team (Consultants, middle grade doctors and parkinson’s
specialist nurses)
-
Doctors
-
Registered nurses
-
Pharmacists and medicine management technicians
Clinical area(s)
Foundation Trust (KMH, NH, MCH) caring for and treating adult patients. Patient group(s)
• Adult patients 18 and above
Exclusions
• Paediatrics under the age of 18
• Obstetric and maternity patients
Related Trust policies and guidelines and/or other Trust documents
1. Consentpolicy
2. MentalCapacitypolicy.
3. DEFINITIONS AND/OR ABBREVIATIONS
Trust: Sherwood Forest Hospitals NHS Foundation Trust
Staff: All employees of the Trust including those managed by a third party on
behalf of the Trust PD Parkinson’s disease
NBM Nil by Mouth
NG Nasogastric tube
HCOP Health Care of the Older Person COMT Catechol-O-methyl transferase
4. ROLES AND RESPONSIBILITIES
The management of patients with Parkinson’s disease and swallowing difficulties requires a multidisciplinary approach supervised by a Parkinson’s specialist team member.
The medical team has the responsibility for the overall management of the patient. The medical team will hold responsibility for all prescribing issues and will liaise with Speech and Language Therapists (SALT), Pharmacists and Parkinson’s team in provision of appropriate treatment for the patient.
The Parkinson’s team is responsible for providing specialist assessment, advice and direct patient interactions and will promote the application of this guideline to the care of individual patients.
The medical team has the responsibility to ensure that the correct lawful consent has been gained and documented in appropriate setting. If capacity is in doubt, a two- stage test should be undertaken. If the patient is found to lack capacity, complete the best interest checklist and plan care in their best interests. Please see the Trust’s “Consent Policy” and “Mental Capacity Act Policy” for further information.
5. GUIDELINE
Please make an urgent pink form referral to Parkinson’s team – Please fax this to
Related Trust policies and guidelines and/or other Trust documents
1. Consentpolicy
2. MentalCapacitypolicy.
3. DEFINITIONS AND/OR ABBREVIATIONS
Trust: Sherwood Forest Hospitals NHS Foundation Trust
Staff: All employees of the Trust including those managed by a third party on
behalf of the Trust PD Parkinson’s disease
NBM Nil by Mouth
NG Nasogastric tube
HCOP Health Care of the Older Person COMT Catechol-O-methyl transferase
4. ROLES AND RESPONSIBILITIES
The management of patients with Parkinson’s disease and swallowing difficulties requires a multidisciplinary approach supervised by a Parkinson’s specialist team member.
The medical team has the responsibility for the overall management of the patient. The medical team will hold responsibility for all prescribing issues and will liaise with Speech and Language Therapists (SALT), Pharmacists and Parkinson’s team in provision of appropriate treatment for the patient.
The Parkinson’s team is responsible for providing specialist assessment, advice and direct patient interactions and will promote the application of this guideline to the care of individual patients.
The medical team has the responsibility to ensure that the correct lawful consent has been gained and documented in appropriate setting. If capacity is in doubt, a two- stage test should be undertaken. If the patient is found to lack capacity, complete the best interest checklist and plan care in their best interests. Please see the Trust’s “Consent Policy” and “Mental Capacity Act Policy” for further information.
5. GUIDELINE
Please make an urgent pink form referral to Parkinson’s team – Please fax this to
MAOB Monoamine oxidase B
KMH Kings Mill Hospital
NH Newark Hospital
MCH Mansfield Community Hospital
SALT Speech and Language Therapist
HCOP Secretary-3587 (internal)
Seek advice from the ward Pharmacists if necessary
Do not stop Parkinson’s medications suddenly except followings as this can lead to serious withdrawal problems.
Medications that can safely be omitted until able to swallow are
COMT inhibitors - entacapone / tolcapone MAOB inhibitors - selegiline/ rasagiline amantadine
Do not prescribe medications that can worsen Parkinson’s symptoms - metoclopramide, haloperidol, prochlorperazine.
Ondansetron can be used in patient’s where an anti-sickness is necessary (This is preferred to cyclizine)
If on apomorphine continue as prescribed. Seek advice from the Pharmacist.
Refer to the flow chart below for immediate management options
Request an urgent Speech and Language Therapy assessment And follow the flow chart
Seek advice from the ward Pharmacists if necessary
Do not stop Parkinson’s medications suddenly except followings as this can lead to serious withdrawal problems.
Medications that can safely be omitted until able to swallow are
COMT inhibitors - entacapone / tolcapone MAOB inhibitors - selegiline/ rasagiline amantadine
Do not prescribe medications that can worsen Parkinson’s symptoms - metoclopramide, haloperidol, prochlorperazine.
Ondansetron can be used in patient’s where an anti-sickness is necessary (This is preferred to cyclizine)
If on apomorphine continue as prescribed. Seek advice from the Pharmacist.
Refer to the flow chart below for immediate management options
Request an urgent Speech and Language Therapy assessment And follow the flow chart
Table 1
Guidance on Crushing tablets
Medicine Name
|
Standard release
dopamine agonist
(Pramipexole and
Ropinirole)
|
Advice
Use same dose and timing (crushed and disperse)
Use same dose and timing (crushed and disperse)
Convert total
dopamine agonist
dose into equivalent
Rotigotine dose
Refer to Table 3
Refer to Table 3
Prolonged release
dopamine agonist
(Mirapexin PR and
Requip XL)
|
Levodopa
(co-beneldopa/
co-careldopa and
Stalevo)
|
Similar dose but convert to standard release formula and administer in
three divided doses (crushed and disperse) - See Table 5
Use dispersible Madopar (crushed and disperse) – Please refer to Table 4
Crushing of tablets should only be considered for short-term use only until the patient reviewed by the PD team.
Do not cruse prolong release formula.
Use dispersible Madopar (crushed and disperse) – Please refer to Table 4
Crushing of tablets should only be considered for short-term use only until the patient reviewed by the PD team.
Do not cruse prolong release formula.
Table 2
Conversion of Levodopa into Rotigotine transdermal patch
Conversion of Levodopa into Rotigotine transdermal patch
co-careldopa &
co-beneldopa
(Madopar / Sinemet)
|
Starting
Rotigotine
Dose
|
co-careldopa +
entacapone - (Stalevo)
(according to the
co-careldopa dose)
|
Starting
Rotigotine
Dose
|
up to 62.5 mg TDS
|
2mg/24hrs
|
up to 50mg TDS
|
2mg/24hrs
|
above 62.5mg TDS
up to 62.5mg QDS
|
4mg/24hrs
|
above 50mg TDS
up to 75mg TDS
|
4mg/24hrs
|
above 62.5mg QDS
up to 125mg TDS
|
6mg/24hrs
|
above 75mg TDS
up to 100mg TDS
|
6mg/24hrs
|
above 125mg TDS
up to 125mg QDS
|
8mg/24hrs
|
above 100mg TDS up
to 100mg QDS
|
8mg/24hrs
|
above 125mg QDS
up to 187.5mg QDS
|
10mg/24hrs
|
above 100mg QDS up
to 150 QDS
|
10mg/24hrs
|
above 187.5mg QDS
|
12mg/24hrs
|
above 150mg QDS
|
12mg/24hrs
|
Table 3
Conversions of oral dopamine agonist into Rotigotine transdermal patch
Conversions of oral dopamine agonist into Rotigotine transdermal patch
Pramipexole
(Base) |
Pramipexole
Prolonged release
(Base)
|
Ropinirole
|
Ropinirole
XL
|
Rotigotine
Patch
|
88micrograms TDS
|
260micrograms OD
|
Starter pack
|
2mg/24hrs
|
|
180micrograms TDS
|
520micrograms OD
|
1mg TDS
|
4mg OD
|
4mg/24hrs
|
350micrograms TDS
|
1.05mg OD
|
2mg TDS
|
6mg OD
|
6mg/24hrs
|
530micrograms TDS
|
1.57mg OD
|
3mg TDS
|
8mg OD
|
8mg/24hrs
|
700micrograms TDS
|
2.1 mg OD
|
4mg TDS
|
12mg OD
|
10-12mg/24hrs
|
880micrograms TDS
|
2.62mg OD
|
6mg TDS
|
16mg OD
|
14mg/24hrs
|
Please use the pramipexole BASE formulation dose for conversion as above
Refer to BNF / Seek Pharmacist’s help
Table 4
Calculating equivalent dispersible Madopar® dosing
You can use one tablet of dispersible Madopar 125mg instead of 2 tablet of dispersible Madopar 62.5mg tablets. (4 X 62.5mg dispersible Madopar = 2 x125mg dispersible Madopar)
Calculating equivalent dispersible Madopar® dosing
You can use one tablet of dispersible Madopar 125mg instead of 2 tablet of dispersible Madopar 62.5mg tablets. (4 X 62.5mg dispersible Madopar = 2 x125mg dispersible Madopar)
Co-Careldopa
(carbidopa/
levodopa)
Sinemet;
including CR
|
Dispersible
Madopar
dose
|
Co-Beneldopa
(benserazide/levodopa)
Madopar; including
CR
|
Dispersible
Madopar
dose
|
Co-Careldopa +
entacapone
Stalevo;
|
Dispersible
Madopar
dose
|
62.5mg
(12.5/50)
|
62.5mg
(12.5/50)
|
62.5mg
(12.5/50)
|
62.5mg
(12.5/50)
|
50mg
(50/12.5/200)
|
62.5mg
(12.5/50)
|
110mg
(10/100)
|
2x
62.5mg
|
125mg
(25/100)
|
2 x 62.5mg
|
75mg
75/18.75/200
|
2 x 62.5mg
|
125mg
(25/100)
|
2x
62.5mg
|
250mg
(50/200)
|
4 X 62.5mg
|
100mg
100/25/200
|
2X
62.5mg
|
275mg
(25/250)
|
5X
62.5mg
|
CR-125mg
(25/100)
|
2 x 62.5mg
|
125mg
125/31.25/200
|
2 x 62.5mg
|
CR-125mg
(25/100)
|
2x
62.5mg
|
150mg
150/37.5/200
|
3 x 62.5mg
|
||
CR-250mg
(50/200)
|
4X
62.5mg
|
175mg
175/43.75/200
|
3 x 62.5mg
|
||
200mg
200/50/200
|
4 x 62.5mg
|
Eg –
co-beneldopa 125 mg TDS = dispersible Madopar 125 mg TDS or 2 X 62.5 mg TDS
Table 5
Conversion of XL dopamine agonist in to standard release agonist
Conversion of XL dopamine agonist in to standard release agonist
Pramipexole
Prolonged release
(Base)
|
Pramipexole
standard release
(Base)
|
Ropinirole
Prolonged release
|
260micrograms OD
|
88micrograms TDS
|
2mg OD
|
520micrograms OD
|
180micrograms TDS
|
4mg OD
|
1.05mg OD
|
350micrograms TDS
|
6mg OD
|
1.57mg OD
|
530micrograms TDS
|
8mg OD
|
2.1 mg OD
|
700micrograms TDS
|
12mg OD
|
2.62mg OD
|
880micrograms TDS
|
16mg OD
|
Ropinirole
standard releas
0.5mg TDS
1mg TDS 2mg TDS 3mg TDS 4mg TDS 6mg TDS
0.5mg TDS
1mg TDS 2mg TDS 3mg TDS 4mg TDS 6mg TDS
6. EVIDENCE BASE / REFERENCES
e
-
Switching dopamine agonist in advanced Parkinson disease; Rapid titration;
Christopher G,Goetz, Lucy Blasucci, Glenn T: American Academy of Neurology
2006;1227-1229
-
An overnight switch to Ropinirole therapy in patients with parkinson disease.
Canesi M, Antonini A, Mariani CB, Tesei S, Barichella M. J of Neural
Transmission;1999;106: 925-929
-
Switching and combination of dopamine agonist. H Reichmann, B Herting, A
Muller, U Sommer. Journal of Neural Transmission; 2006; 110:1393-1400
-
Rotigotine for peri-operative management of Parkinson’s disease. Journal of
Neural Transmission 2010; 117:855-859
-
Goetz CG, Shannon KM, Tanner CM. Agonist substitution in advanced parkinson
disease. Neurology 1989; 39:1121-1122
-
Rotigotine transdermal system for perioperative administration. AD Corczyn, H
Reichmann, B Boroojerdi. J Neural Transmission 2006;114:219-221
-
Overnight switch from oral dopamine agonist to transdermal Rotigotine in
Parkinson Disease. Peter A, Babk B, Douglas M. Clinical
Neuropharmacology.2007:30:256-264
-
Parkinson study group. A controlled trial of Rotigotine monotherapy in early
Parkinson’s disease. Arch Neurol 2003;60;1721-1728
- British National Formulary
disease. Intern med J. 2006 Aug;36(8):524-6
11. Woodford H, Walker R. Emergency hospital admissions in idiopathic
Parkinson’s disease. Movement Disorder. 2005;20(9):1104-84.
12. Brennan KA, Genever RW. Managing Parkinson’s disease during surgery.
BMJ; 2006;1;341:990-993
13. Ramig L, Fox C, Sapir S. Speech Treatment for Parkinson disease. Expert Rev
Neurotherapeutics 2008; 8:299–311.
14. Parkinson’s Disease UK – Parkinson’s disease acute management
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