Acute management of Parkinson s

Transcription

1 Acute management of Parkinson s Fife Parkinson s Service

2 Contents 1. Introduction 2. On admission to hospital 3. If Patient has compromised swallow or is nil by mouth 4. Conversion charts if patient on levodopa preparations 5. Advice regarding dopamine agonists if swallow compromised 6. Switch guidelines 7. Apomorphine guidelines 8. Conclusion 9. Fife Parkinson s Team Contacts 2

3 1. Introduction Parkinson s Disease is a progressive degenerative neurological condition associated with loss of Dopamine producing neurons in the substantia nigra. The cardinal features of Parkinson s are: 1. Slowness of movement 2. Muscle rigidity 3. Tremor 4. Postural instability (not in early stages) Parkinson s is a condition which affects movement and motor function but it is also a condition which causes many non motor symptoms including depression, anxiety and pain. Medication is crucial in optimal management of Parkinson s. If medication is not given this can result in patients being unable to swallow and so be at high risk of aspiration, be unable to speak, move and become more dependent on staff. It can also lead to increased falls and higher risk of fractures. At worst it may develop into Neuroleptic Malignant Type Syndrome which can be fatal. People with Parkinson s are admitted to hospital for many reasons, very often 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 if the Parkinson s Specialist Team is 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 more appropriately on admission i.e. receiving some anti-parkinsonian medication until they can be seen by a member of the Parkinson s Team to provide specialist advice on complex medicines management. 3

4 2. On admission 1. Obtain accurate drug history from sources including patient, carer or Emergency Care Summary (ECS): 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 3. Obtain medication as soon as possible. If patient has brought in own medication please use this if in pharmacy- labelled bottles which are current or a NOMAD can be used as long as it has been dispensed by a Pharmacist and the medication can easily be identified (NHS Fife Code of Practice Medicine Policy 1.9 section 4.4) 4. DO NOT STOP PARKINSON S MEDICATIONS! 5. Do not prescribe medications which can worsen Parkinson s symptoms i.e. metoclopramide, haloperidol, prochlorperazine, cyclizine. If patient requires anti-emetics, please use domperidone. Ondansetron can also be used (off label) 6. If on apomorphine please contact Parkinson s Team ASAP or Apo-go Helpline if team unavailable 4

5 3. If Patient has compromised swallow or is nil by mouth Contact PD Specialist Team ASAP & Speech & Language Therapist If unable to contact PD Team (e.g. out of hours) please continue through flow chart Is patient on combination of levodopa preparations and dopamine agonists? Yes Convert levodopa preparation to equivalent rotigotine patch strength (see guideline section 4) No Follow guidelines To switch existing medication to rotigotine patch equivalent dose (See section 4 or 5 in guideline) Convert equivalent dopamine agonist dose to rotigotine patch strength (see guideline section 5) Is total rotigotine equivalent dose more than 16mg? (Maximum dose) (0ff label use if used as monotherapy i.e. without levodopa) YES Ensure NG tube is passed to allow dispersible levodopa equivalent to be administered if possible and use patch for equivalent dopamine agonist NO Prescribe recommended rotigotine dose If NG tube not appropriate use maximum dose rotigotine (16mg) and contact PD Specialist team ASAP 5

6 4. Conversion table: Brand Name Sinemet Madopar Stalevo e.g. Generic Name Alternative Dose Co-careldopa Co-beneldopa Levodopa/carbidopa/entacapone Madopar dispersible Convert according to levodopa dose Madopar 62.5mg = 12.5/50 ( benserazide 12.5mg/levodopa 50mg) Co-careldopa 125mg = 25/100 (carbidopa 25mg/levodopa 100mg) Rotigotine conversion tables if only on levodopa preparations Current levodopa regime Madopar or Sinemet 62.5mg BD 2mg/24hrs Madopar or Sinemet 62.5mg TID 4mg/24hrs Madopar or Sinemet 62.5mg QID 6mg/24hrs Madopar or Sinemet 125mg TID 8mg/24hrs Madopar or Sinemet 125mg QID 10mg/24hrs Madopar or Sinemet 187.5mg TID 12mg/24hrs Madopar or Sinemet 187.5mg QID 16mg/24hrs Rotigotine patch equivalent Madopar or Sinemet 250mg TID Madopar or Sinemet 250mg QID 16mg/24hrs 16mg/24hrs (Note max. daily dose of rotigotine is 16mg/24 hours) 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 TID and Madopar CR nocte: equivalent rotigotine dose =6mg/24hr Current Stalevo regime Stalevo 50/12.5/200 TID Stalevo 100/25/200 TID Stalevo 100/25/200 QID Stalevo 150/37.5/200 TID Stalevo 200/50/200 TID Rotigotine patch equivalent mg /24hrs 6mg 10mg 14mg 16mg 16mg Medication which can safely be omitted if swallow is compromised COMT inhibitors: entacapone MAOB inhibitors: selegiline/rasagiline/zelapar amantadine (Symmetrel) 6

7 5. Advice regarding Dopamine Agonists if swallow compromised (if only on a Dopamine agonist for Parkinsons) Current Dopamine Agonist Advice Rotigotine (Neupro) Continue Apomorphine S/C injection or Continue. Use familiar pump if infusion unsure of Apo-go pump DO NOT STOP (contact PD Team or HAN team or Apo helpline ) Pramipexole (Mirapexin) Can be crushed ** Ropinirole (Requip) Can be crushed ** Requip XL Convert to standard equivalent dose ropinirole TDS and crush**e.g. 24mg XL = 8mg TDS ** Unlicensed use. 6. Switch guidelines from oral dopamine agonist to rotigotine transdermal patch Pramipexole (salt content) Ropinirole Requip Requip XL Rotigotine patch 0.125mg tds Starter pack N/A 2mg/24hr 0.25mg tds 1mg tds 4mg/day 4mg/24hr 0.5mg tds 2mg tds 6mg/day 6mg/24hr 0.75mg tds 3mg tds 8mg/day 8mg/24hr 1mg tds 4mg tds 12mg/day 10-12mg/24hr 1.25mg tds 1.5mg tds 6mg tds 8mg tds 16mg/day 24mg/day 14mg/24hr 16mg/24hr NB Maximum dose of rotigotine is 16mg/24hrs Patches available in 2mg/4mg/6mg/8mg strengths Do not cut patches to achieve correct dose 7

8 7. Apomorphine guidelines Under no circumstances must this be initiated without involvement by a Parkinson s Specialist. If a patient is admitted and is on apomorphine please see NHS Fife Shared Care protocol regarding the use of apomorphine. (on ADTC website via intranet) Please contact the Fife Parkinson s Service ASAP or contact Apo-go helpline is out of hours for advice. Hospital at Night practitioners (H@N) are available for advice if out of hours. 8. Conclusion Parkinson s is a complex neurological condition and appropriate management during hospital admission is paramount to avoid potential problems with delayed recovery, post operative complications, delayed discharges and ultimately poor experiences for patients. This document has been developed to provide guidance to clinical staff when involved in the care of a patient with Parkinson s. It must be stressed that the Parkinson s Specialist Team must be contacted at the earliest opportunity to provide advice. For further information please also see Clinical Guidance Document on Guidelines for Managing Parkinson s Pre and Post -operatively (available on NHS Fife Intranet) 9. Fife Parkinson s Team contacts Parkinson s Nurse Specialists: Joy Reid Nancy Gallagher and Lynda Kearney ext Consultants: Dr Nicola Chapman ext QMH Dr Elizabeth Keane ext VHK Dr Susan Pound ext QMH Dr Uwe Spelmeyer ext VHK Dr Aylene Kelman ext VHK Dr Martin Zeidler ext VHK Useful references: Brennan K, Genever R: Algorithm for estimating parenteral doses of drugs for Parkinson s Disease, BMJ 2010: 341 NEWT guidelines (2010) 2 nd edition 8