Doncaster & Bassetlaw Medicines Formulary

Transcription

1 Doncaster & Bassetlaw Medicines Formulary Section 4.9: Drugs Used in Parkinsonism and related Disorders Co-Beneldopa 12.5/50, 25/100 and 50/200 (Madopar) Capsules Co-Beneldopa 12.5/50 and 25/100 Dispersible (Madopar) Tablets Co-Beneldopa 25/100 Modified Release (Madopar CR) Capsules Co-Careldopa 12.5/50 (Sinemet 62.5) and 25/100 (Sinemet Plus) Tablets Co-Careldopa 25/100 Modified Release (Half Sinemet CR) and 50/200 Modified Release (Sinemet CR) Tablets Pergolide 50 micrograms, 250 micrograms and 1mg tablets Cabergoline 500 micrograms, 1mg and 2mg tablets Bromocriptine 1mg, 2.5mg & 10mg tablets/capsules Ropinirole 250 micrograms, 1mg, 2mg and 5mg tablets Pramipexole (as base) 88 microgram, 180 microgram and 700 microgram tablets Entacapone 200mg tablets Selegiline 5mg and 10mg tablets Selegiline 10mg/5ml oral liquid Amantadine 100mg capsules Amantadine 50mg/5ml syrup Procyclidine 5mg tablets Procyclidine 5mg/5ml syrup Procyclidine 10mg/2ml injection Items for Restricted Prescribing Apomorphine 20mg in 2ml injection Rasagiline 1mg tablet Rotigotine 2mg/24 hours, 4mg/24 hours, 6mg/24 hours and 8mg/24 hours Patch Stalevo 50mg/12.5mg/200mg, 100mg/25mg/200mg and 150mg/37.5mg/200mg tablets Tolcapone 100mg tablets Botulinum Toxin (Botox) 50unit and 100unit Injection Approved by Drug and Therapeutics Committee: February 2014 Review Date: February 2016 KEY: [UL] Unlicensed Preparation; Drug first line choice; Drug hospital only; Drug Amber (TLS), Drug Red (TLS), see

2 Prescribing Guidance: See also NICE Guidance (CG35) A shared care protocol for drugs used in the treatment of Parkinson s disease can be found via the Doncaster PCT Website Levodopa It is not possible to identify a universal first-choice drug therapy for people with early Parkinson s Disease (see also NICE Guidance - section 1.4.1) Levodopa is combined with the peripheral dopa-decarboxylase inhibitors benserazide (Madopar) and carbidopa (Sinemet). To achieve a full inhibition of extracerebral dopa-decarboxylase 25mg of benserazide/carbidopa should be used for each 100mg of levodopa, so that the daily dose of carbidopa is at least 75mg. Sinemet 110 and Sinemet 275 contain a less than ideal balance of levodopa to carbidopa and should not be used alone to treat Parkinson s Disease. Note: Sinemet 62.5 was previously marketed as Sinemet LS Dosage: see current BNF for each preparation. The dose of levodopa should be kept as low as possible to maintain good function in order to reduce the development of motor complications. Dispersible preparations work within 10 minutes, with a duration of action of about 60 minutes. Controlled release levodopa preparations can provide smoother control with fewer side effects. They are not recommended as first choice options in either early or late Parkinson s Disease (see also NICE Guidance). Noncontrolled release preparations should usually be prescribed in conjunction as well. They still have to be given 3 times a day and often non-controlled release preparations need to be given in the morning as well. Where the preparation is unknown or not specified capsules will be supplied. It is advised to take both brands with or after food to avoid nausea. However in late disease it may be advantageous to take on an empty stomach to reduce competition for levodopa absorption from dietary amino acids.

3 Dopamine Agonists It is not possible to identify a universal first-choice drug therapy for people with early Parkinson s Disease. The choice of drug first prescribed should take into account: clinical and lifestyle characteristics patient preference, after the patient has been informed of the shortand long-term benefits and drawbacks of the drug classes (see also NICE Guidance - section 1.4.1). Where a dopamine agonist is required, a non-ergot derivative is now preferred in most cases. Common side effects of dopamine agonists: Nausea and vomiting, postural hypotension, somnolence, neuro-psychiatric disturbances (hallucinations), less incidence of dyskinesias than levodopa Side effects associated with ergot derived dopamine agonists: Pulmonary fibrosis, pleuritis and pleural fibrosis. Before starting treatment it may be appropriate to measure ESR and serum creatinine, and to obtain a chest x-ray. Patients should be regularly monitored for dyspnoea, persistent cough, chest pain & abdominal tenderness Sudden onset of sleep has been associated with dopamine agonists, cobenaldopa & co-careldopa. Patients should be warned of the possibility of this effect and might need to exercise caution when driving or operating machinery All of the dopamine agonists are classified as AMBER under the shared care guidance (see link above). This means that they are prescribable in primary care in line with the shared care guidance. Pramipexole Should be prescribed in terms of Pramipexole base. Equivalent strengths in terms of Pramipexole dihydrochloride monohydrate (salt) are: 88mcg base 125mcg salt 180mcg base 250mcg salt 700mcg base 1mg salt Rotigotine Should only be prescribed where the oral route is not appropriate and the patch formulation is deemed to be appropriate. Apomorphine For specialist initiation only

4 COMT Inhibitors Entacapone Dosage: 200mg with each dose of levodopa (maximum 2g per day) May allow for up to 30% reduction in concurrent levodopa dose. In view of concordance issues, those patients with later Parkinson s Disease taking entacapone may benefit from a triple combination preparation of levodopa, carbidopa and entacapone (Stalevo). This should be initiated by a specialist in the treatment of Parkinson s Disease. Side Effects associated with COMT inhibitors: Urine discolouration, nausea & vomiting, neuro-psychiatric disturbances. Prescribable in primary care in line with shared care guidance. This includes the Stalevo combination preparation. Tolcapone Hospital prescribing only MAO-B Inhibitors Selegiline Dosage: 5mg OM and 5mg lunchtime or 10mg OM (in the elderly, start treatment at 2.5mg daily) Also available in oral lyophilisates (Zelapar) Dosage: initially 1.25mg before breakfast Counselling: Tablets should be placed on the tongue and allowed to dissolve. Advise patients not to drink, rinse or wash mouth out for 5 minutes after taking the tablet. Note: Zelapar 1.25mg = 10mg tablet Common side effects: Insomnia, hallucinations, postural hypotension Rasagaline Dosage: 1mg daily Potential Interaction with SSRIs and TCAs antidepressants

5 Prescribable in primary care in line with shared care guidance Amantadine Useful for dyskinesias in later Parkinson s Disease. Dosage 200 to 400mg/day, usually before 2pm Side Effects: confusion and hallucinations Prescribable in primary care in line with shared care guidance Anti-Cholinergics The anti-cholinergic drugs are prescribed infrequently as they are generally less effective in controlling bradykinesia. They may be useful in reducing tremor and rigidity when used in conjunction with levodopa. They are generally avoided in idiopathic Parkinson s Disease as they are associated with cognitive impairment. They may be useful for controlling sialorrhoea. The main use is in treatment of drug-induced Parkinsonism which is seen with antipsychotic drugs (where it is not possible to withdraw treatment), and occasionally with prochlorperazine or metoclopramide in the management of nausea and vomiting.