2 Statement of Intent 3 3 Scope 3 4 Definitions 3 5 Duties & Responsibilities 3 6 Consequences of missing Parkinson’s medicines 4 7.0 Parkinson’s disease management in patients – secondary care 4 7.1a) Patients with a compromised swallow or nil by mouth in secondary care 4 7.1b) Hospital – Surgery/NG patients (flow chart) 5 7.2 a) Patients with a compromised swallow or Nil by Mouth in primary care 5 - 6 8.0 Nasogastric administration of Levodopa and Dopamine agonist 6 - 7 9.0 Conversion table for transdermal delivery 8 10.0 Drugs to avoid in Parkinson’s disease 8 11.0 Apomorphine guidelines 8 12.0 Contact details 9 13.0 References and acknowledgements 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 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 intent This document is designed to rationalise the prescribing in this patient group. SCOPE The 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 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 Nasogastric NMS Neuroleptic Malignant Syndrome Pd Parkinson’s disease L-Dopa Levodopa COMT Catechol-o-methyl transferase CR Controlled release DUTIES & RESPONSIBILITIES For 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 drugs Medication 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.
Co-Beneldopa Dopamine. Can be used at all stages of the disease process. Works well on stiffness and bradykinesia Dyskinesia Drowsiness Hallucinations Postural hypotension Dopamine Agonist Pramipexole Ropinerole Stimulates post synaptic dopaminergic receptors Nausea/vomiting Hallucinations Impulse Control Disorder Confusion Monoamine oxidase type B (MAO-B) inhibitors Selegiline Rasagiline Slows the metabolism of Dopamine Drug is a stimulant, therefore should be taken in the morning COMT inhibitors Entacapone Stalevo Blocks the metabolism of Dopamine Will increase side effects of L-dopa Anticholinergics Trihexyphenidyl (Benzhexol) Blocks the action of Acetylcholine (which breaks down Dopamine) Limited efficacy Neuro-psychiatric side effects Glutamate Agonist Amantadine Enhances the release of Dopamine. Anticholinergic properties 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 Treatment of Hallucinations /Confusion Treatment of Nausea / Vomiting Vigilance is required with the use of
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 All Health Care Professionals DATIX Incident Reporting System Quarterly Quarterly Aggregated Report of Incidents to the Clinical Quality Safety and Patient Experience Committee Depending on Compliance, outcome and clinical or operational area – Director Lead or Manager assigned. Directorate Risk Management Groups Inpatient audit Alison Waldron Audit Every 6 months Report to Directorate Depending on outcome – Lead Consultant will act aPPENDIX 5 – rEVIEW AND MONITORING ADHERANCE TO GUIDELINES