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847725843280Management of Parkinson’s Disease in Primary and Secondary Care for patients with compromised swallow or those patients deemed Nil By Mouth.00Management of Parkinson’s Disease in Primary and Secondary Care for patients with compromised swallow or those patients deemed Nil By Mouth.375920150368000370205998347000To 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 (Parkinson’s disease Nurse Specialist – community based)VERSION CONTROLJune 20141.0This is a new documentAugust 2014Consultation with Dr Martin GP and Dr Bowen Palliative Care Consultant Consultation with consultants in secondary care - Dr MichaelDr StellmanDr McGrathDr IjaolaDr LewthwaiteDr DouglasReview of document – version 1.1December 2014 Version 1.1 Circulated to GP’s PBP’s DGNHSFT Consultants DGNHSFT Nurses Dudley CCG Dudley MBC NOC Project Support CCG Head of CommissioningA translation service is available for this document. The Interpretation/Translation Policy, Guidance for Staff is located on the intranet under Trust-wide Policies.SectionContentsPage Number1Introduction32Statement of Intent33Scope34Definitions35Duties & Responsibilities36Consequences of missing Parkinson’s medicines47.0Parkinson’s disease management in patients – secondary care47.1a)Patients with a compromised swallow or nil by mouth in secondary care47.1b)Hospital – Surgery/NG patients (flow chart)57.2 a)Patients with a compromised swallow or Nil by Mouth in primary care5 - 68.0Nasogastric administration of Levodopa and Dopamine agonist6 - 79.0Conversion table for transdermal delivery810.0Drugs to avoid in Parkinson’s disease 811.0Apomorphine guidelines812.0Contact details913.0References and acknowledgements9 Appendix 1Common oral medicines used in Parkinson’s disease10Appendix 2Commonly used drugs to avoid in Parkinson’s disease11Appendix 3Conversion algorithm12Appendix 4Conversion charts13Appendix 5Review and monitoring adherence to guideline141.INTRODUCTIONClinical experience and audit has revealed that Parkinson’s patients who are nil by mouth (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.Statement of intentThis document is designed to rationalise the prescribing in this patient group. SCOPEThe Parkinson’s disease Specialist Nurses 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 diseaseThe Area Clinical Effectiveness Committee will oversee the ratification of the guideline and appropriate review.4. DEFINITIONSCK Creatinine KinaseMAO-BMonoamine oxidase B inhibitorNBMNil by mouthNG NasogastricNMS Neuroleptic Malignant SyndromePd Parkinson’s diseaseL-Dopa LevodopaCOMT Catechol-o-methyl transferaseCR Controlled release DUTIES & RESPONSIBILITIESFor patients managed in primary care please contact Trudy Gaskin (Parkinson’s disease Nurse Specialist) 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.consequences of missing parkinson’s disease drugsMedication is crucial in optimal management of Parkinson’s disease. 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. 647700-454660Neuroleptic Malignant SyndromeRareDue to sudden withdrawal of PD medicationHyperthermia, muscle rigidity, altered level of consciousness, autonomic instability and elevated serum creatinine kinase (CK) levelOnset within 1 to 9 daysMajor complications are respiratory, renal and cardiovascular failureCarries significant mortality 020000Neuroleptic Malignant SyndromeRareDue to sudden withdrawal of PD medicationHyperthermia, muscle rigidity, altered level of consciousness, autonomic instability and elevated serum creatinine kinase (CK) levelOnset within 1 to 9 daysMajor complications are respiratory, renal and cardiovascular failureCarries significant mortality People with Parkinson’s disease 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 parkinson’s disease MANAGEMENT IN patients – SECONDARY CARE7.1a)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 disease 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 a patient to Rotigotine transdermal patch pre-operatively. Discuss with Parkinson’s nurse specialist/Neurology specialist pharmacist but in an emergency the online conversion calculator can be used to switch to Rotigotine transdermal patch. See online calculatorNote: 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 CHARTIf you think the patient’s swallow is compromised follow the following algorithm:center0Contact Acute Clinical Nurse Specialist for Parkinson’s disease – Bleep 5026Refer to Speech and Language therapy via Soarian020000Contact Acute Clinical Nurse Specialist for Parkinson’s disease – Bleep 5026Refer to Speech and Language therapy via Soarian2614295749300027158956223000If 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)27158959398000center-1934210Contact Acute Clinical Nurse Specialist for Parkinson’s disease – Bleep 5026Refer to Speech and Language therapy via Soarian020000Contact Acute Clinical Nurse Specialist for Parkinson’s disease – Bleep 5026Refer to Speech and Language therapy via SoarianCan the patient tolerate a nasogastric (NG) tube?1668145501650037045905016500 YES NO290576020955Convert to Rotigotine patch – see Hub400000Convert to Rotigotine patch – see Hub34671019685Follow NG administration guidelines (section 8)400000Follow NG administration guidelines (section 8)7.2 a) patients with a compromised swallow or nil by mouth in primary careDue to the characteristics of Parkinson’s disease, patients may experience symptoms which lead to changes in their ability to swallow safely. In turn this may lead to life threatening conditions and reduced quality of life. It is therefore important to recognise and inform patients and their families of the warning signs of a swallowing disorder in order to provide early intervention and work with patients and their families in appropriate management and advance care planning.Early warning signs of a compromised swallowDrooling Coughing or choking on food and / or drinkFood sticking/pouchingChanges to speechFrequent chest infectionsCognitive changesChanges to a patients swallow may develop gradually or more quickly depending on the cause. It is therefore necessary to assess patient’s individual circumstances and history to determine the next appropriate actions.A referral should be completed requesting an assessment from speech and language therapists and dietician service. Advice should also be sought from Trudy Gaskin (Parkinson’s disease Nurse Specialist) and / or Dr Janine Barnes (Neurology Specialist Pharmacist). To access these professionals through the Dudley Rehabilitation Service a combined referral form is available on the HUB, Dudley Group of Hospitals webpage or telephone 01384 323145. In some situations it may become necessary for a patient to be transferred to hospital for nasogastric or percutaneous endoscopic gastrostomy. Medication changes can be made by using this guidance and conversion charts below.If a patient is recognised to be in the palliative / end of life care stages of Parkinson’s disease please refer to the Palliative Care guidelines.8. NasoGastric administration of Levodopa and Dopamine AgonistOn occasions it may be necessary to administer Parkinson’s medications via an NG tube temporarily although these recommendations can be followed for long term enteral administration.Normal prescriptionMethod of administration/alternativeCo-Beneldopa (Madopar)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 blockageCo-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.2CR formulations require a slight dose reduction.1Sinemet (Co-Careldopa)Madopar (Co-Beneldopa)Sinemet 62.5mg tabletMadopar 62.5mg dispersible tabletSinemet 110mg tabletMadopar 125mg dispersible tabletSinemet Plus 125mg tabletMadopar 125mg dispersible tabletSinemet 275mg tablet2 x Madopar 125mg dispersible tabletHalf Sinemet CR 125mg tabletConvert to ordinary formulation doseSinemet CR 250mg tabletConvert to ordinary formulation doseEntacaponeDisperses less easilyEnteral tubes will need to be flushed well after useStalevo (combination of Co-Beneldopa and Entacapone)Give equivalent doses of Co-Beneldopa dispersible as above and Entacapone as above.2 RasagilineContacted the manufacturer, unfortunately no information is available on crushing. Consider switch to Selegiline if patient unable to swallowSelegilineZelapar ( 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)2AmantadineLiquid available (50mg/5ml) – for enteral tubes onlyAmantadine hydrochloride is freely soluble in water.2 The capsules may be opened and mixed with water and administered immediately via an enteral feeding tube.1,2RopineroleMaintain 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.1Ropinerole XLConvert to standard RopineroleCrush as aboveRopiniroleControlled Release Ropinirole (XL)Starter packN/A1mg tds4mg/day2mg tds6mg/day3mg tds8mg/day4mg tds12mg/day6mg tds16mg/day8mg tds24mg/dayPramipexoleMaintain same doses – crush tablets and disperse in water2Pramipexole PR (Prolonged Release)Convert to standard PramipexoleCrush as abovePramipexole(salt content)Pramipexole(base content)0.125mg tds0.088mg tds0.25mg tds0.18mg tds0.5mg tds0.35mg tds0.75mg tds0.53mg tds1mg tds0.7mg tds1.25mg tds0.88mg tds1.5mg tds1.05mg tds9. 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 211.Apomorphine prescribing/dispensingUnder no circumstances should this be initiated without involvement with a Parkinson’s specialist.11. a) HOSPITALIf a patient is admitted on Apomorphine please contact the Parkinson’s disease 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) COMMUNITYFor any community queries regarding Apomorphine please contact Trudy Gaskin or Dr 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 detailsAlison Waldron (Acute Clinical Nurse Specialist in Parkinson’s disease), Dudley Group NHS Foundation Trust. Bleep 5026Trudy Gaskin (Parkinson’s Disease Nurse Specialist)01384 323145 / 0792 070 2109Dr Janine Barnes (Neurology Specialist Pharmacist)01384 323145/ 0782 593 258713.References and AcknowledgementsSmyth J, editor. The NEWT Guidelines for administration of medication to patients with enteral feeding tubes or swallowing difficulties. Print version, 2nd edition published 2012. Online version updated more frequently, available at (subscription required).Handbook of Drug Administration via Enteral Feeding Tubes. Accessed via on 12th March 2013.Cabergoline vs Pergolide vs Pramipexole vs Ropinirole. Grosset et al. Movement Disorders2004;19 (11):1370-4Ropinirole, Pramipexole, Cabergoline vs Rotigotine. Le Witt et al. Clinical Neuropharmacology2007; 30 (5): 256- 65Ropinirole vs Requip XL. Summary of product Characteristics, Requip XL. Electronic Medicines Compendium.Algorithm for estimating parenteral doses of drugs for Parkinson’s disease. Brennan K, Genever R. BMJ 2010;341Acute management of PD patients with compromised swallow or NBM. Formulated by PDNS North west.Acute management of Parkinson’s patients. NHS Fife. 2011.NHS Tayside guide to the administration of medicines in the peri-operative period June 2012NHS 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 CareAppendix 1Common Oral Medications Used in Parkinson’s diseaseType of DrugDrug NameHow it WorksPrecautionsLevodopaCo-CareldopaCo-BeneldopaSinemetMadoparL-dopa is the precursor of Dopamine. Can be used at all stages of the disease process. Works well on stiffness and bradykinesiaBecomes less effective over time.DyskinesiaDrowsinessHallucinationsPostural hypotensionDopamine AgonistPramipexoleRopineroleStimulates post synaptic dopaminergic receptorsNausea/vomitingHallucinationsImpulse Control DisorderConfusionMonoamine oxidase type B (MAO-B) inhibitorsSelegilineRasagilineSlows the metabolism of DopamineDrug is a stimulant, therefore should be taken in the morningCOMT inhibitorsEntacaponeStalevoBlocks the metabolism of DopamineWill increase side effects of L-dopaAnticholinergicsTrihexyphenidyl (Benzhexol)Blocks the action of Acetylcholine (which breaks down Dopamine)Limited efficacyNeuro-psychiatric side effectsGlutamate AgonistAmantadineEnhances the release of Dopamine. Anticholinergic propertiesMild effectShort livedInsomniaAppendix 2 COMMONLY USED DRUGS TO AVOIDIf patient already stabilised on therapy review and monitorTable highlighting drugs to avoid (and use) when treating hallucinations and nausea:DrugTreatment of Hallucinations/ConfusionTreatment of Nausea / VomitingVigilance is required with the use ofChlorpromazineXFluphenazineXPerphenazineXTrifluoperazineXFlupenthixolXHaloperidolXQuetiapineClozapine (specialist initiation only)MetoclopramideXProchlorperazineXDomperidoneCyclizineOndansetronAntihistamines?Antidepressants?Antipsychotics?Antihypertensives e.g Calcium Channel Blockers?Key:x – Not recommended –Recommended? – Vigilance requiredAppendix 3Conversion algorithm Algorithm for estimating equivalent Levodopa dosages for Rotigotine patchThis 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.Calculate adjusted LevodopaEquivalent Daily Dose (LEDD):[(A) + (B)] x 0.55 = -------mg13144501549400013144491549400045720028575(A) Total adjusted daily Levodopa dose.Total daily Levodopa dose in mg (excluding Benserazide or Carbidopa).X 0.7 (if MR/CR) or X 1.3 (if on COMT inhibitor) orX 0.91 (if MR/CR and on COMT inhibitor)= ------mg 00(A) Total adjusted daily Levodopa dose.Total daily Levodopa dose in mg (excluding Benserazide or Carbidopa).X 0.7 (if MR/CR) or X 1.3 (if on COMT inhibitor) orX 0.91 (if MR/CR and on COMT inhibitor)= ------mg 310134024130(B) Total adjusted daily Dopamine agonist estimate Levodopa equivalent doseTotal daily Dopamine agonist in mgX 100 (if on Pramipexole/ Cabergoline/ PergolideX 20 (if on Ropinerole)X10 (if on Bromocriptine/ Apomorphine= ------mg(the above figures refer to each medications Levodopa equivalent factor)4000020000(B) Total adjusted daily Dopamine agonist estimate Levodopa equivalent doseTotal daily Dopamine agonist in mgX 100 (if on Pramipexole/ Cabergoline/ PergolideX 20 (if on Ropinerole)X10 (if on Bromocriptine/ Apomorphine= ------mg(the above figures refer to each medications Levodopa equivalent factor)??Calculate dosage for Rotigotine transdermal patch= Adjusted LEDD / 20 = ------mgMaximum Rotigotine dose of 8mg in 24hrs (for monotherapy)Maximum Rotigotine dose of 16mg in 24hrs (Adjunctive therapy)Round to the nearest 2mg (max of 16mg) and prescribe as 24hr patchDO NOT CUT PATCH. Available as 1mg//2mg/3mg/4mg/6mg/8mg patches (can use more than one patch).Appendix 4 Conversion ChartsConversion table for Dopamine AgonistsPramipexole(salt content)Pramipexole(base content)RopiniroleControlled Release RopiniroleRotigotine transdermal patch0.125mg tds0.088mg tdsStarter packN/A2mg/24 hrs0.25mg tds0.18mg tds1mg tds4mg/day4mg/24hrs0.5mg tds0.35mg tds2mg tds6mg/day6mg/24hrs0.75mg tds0.53mg tds3mg tds8mg/day8mg/24hrs1mg tds0.7mg tds4mg tds12mg/day10-12mg/24hrs1.25mg tds0.88mg tds6mg tds16mg/day14mg/24hrs1.5mg tds1.05mg tds8mg tds24mg/dayN/A?Conversion table for Levodopa ?Current Levodopa regime (standard release)Rotigotine transdermal patch equivalentCo-Beneldopa or Co-Careldopa 62.5 bd2mg/24hrsCo-Beneldopa or Co-Carel dopa 62.5 tds4mg/24hrsCo-Beneldopa or Co-Careldopa 62.5 qds6mg/24hrsCo-Beneldopa or Co-Careldopa 125 tds8mg/24hrsCo-Beneldopa or Co-Careldopa 125 qds10mg/24hrs Conversion table for Stalevo ?Current Stalevo regimeRotigotine transdermal patch equivalentDispersible Co-Beneldopa (May need to give smaller, more frequent dosing)50/12.5/200 tds6mg/24hrs62.5mg qds100/25/200 tds10mg/24hrs≡125mg qds100/25/200 qds14mg/24hrs≡125 mg 5 times daily150/37.5/200 tds16mg/24hrs≡ 125 mg 6 times dailyLeadToolFrequencyReporting ArrangementsActing on recommendations and Lead(s)Change in practice and lessons to be sharedAdherence to this guideline through actual and near miss incident reportingAll Health Care ProfessionalsDATIX Incident Reporting SystemQuarterlyQuarterly Aggregated Report of Incidents to the Clinical Quality Safety and Patient Experience CommitteeDepending on Compliance, outcome and clinical or operational area – Director Lead or Manager assigned.Directorate Risk Management GroupsInpatient auditAlison Waldron AuditEvery 6 monthsReport to Directorate Depending on outcome – Lead Consultant will actaPPENDIX 5 – rEVIEW AND MONITORING ADHERANCE TO GUIDELINES ................
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