Parkinson's Disease
Treating patients who can't swallow/absorb
Guidelines on the Management of Parkinson's Disease (PD) Patients with Swallowing Difficulties or Who are 'Nil By Mouth' (NBM)
Background
Patients with PD are often on complicated regimes to manage their disease. If they don't receive their usual medication on time symptoms can quickly increase, along with the risk of adverse inpatient events and prolonged length of stay. When PD medications are withdrawn abruptly patients are also at risk of developing Neuroleptic Malignant Syndrome. It is imperative that if a patient with PD is unable to swallow their usual medication that alternatives are sought. Many of the PD medications can be changed to soluble, crushable or dispersible alternatives and given by mouth or via NG.
Do NOT omit medication
Specialist advice is available during normal working hours. Refer all patients with
concerns regarding swallow who are unable to take their usual medication. Mark as
urgent.
- Older People's Movement Disorder Service: Fax 1287
- Neurology: Fax 1865
Withold entacapone – seek advice
Give oral dopamine agonists via NG – see section 2
Selegiline and rasagiline: disperse in water
– see section 1
Give dopamine agonists as
prepared below – see section 2
NB - Thickener can be added to all preparations when dispersed if needed
Section 1 - Converting Levodopa preparations to Madopar Dispersible
Change all levodopa preparations to the equivalent dose of Madopar Dispersible tablets as below and give at usual timings.
Madopar Dispersible:
- Madopar dispersible is available in strengths of 62.5mg and 125mg
- It can be dissolved in water or orange squash (not orange juice).
- Dispersible tablets will have a faster and shorter duration so monitor the patient for increased dyskinesia at peak dose (usually around 30 mins to an hour after medication), or an increase in PD symptoms before the next dose is due.
- When it is dissolved in water only the clear fluid needs to be given as the active drug is very soluble. The sediment can provoke cough and may block fine bore feeding tubes.
Madopar dispersible tablets are available from pharmacy during normal working hours or check intranet stock list for nearest ward availability. Pulteney Ward keeps stocks of most PD medications - or via Emergency Ward cupboard or on call Pharmacist.
Madopar (co-beneldopa) and Sinemet (co-careldopa) tablets – convert to Madopar dispersible tablets as below:
| Sinemet (co-careldopa) | Madopar (co-beneldopa) | Madopar Dispersible |
| Sinemet 62.5mg | Madopar 62.5mg | Madopar Disp 62.5mg |
| Sinemet 110 | Madopar Disp 125mg | |
| Sinemet Plus | Madopar 125mg | Madopar Disp 125mg |
| Sinemet 275mg | Madopar 250mg | Madopar Disp 125mg x2 |
| Sinemet CR | Madopar Disp 125mg x2 (reduce to 125mg if causes dyskinesia or bad dreams) | |
| Half Sinemet CR | Madopar CR | Madopar Disp 125mg |
Stalevo (Sinemet/entacapone combination) tablets - Change to Madopar Dispersible using this conversion table:
| Stalevo preparations | Madopar dispersible substitute ** |
| Stalevo 50 | Madopar dispersible 62.5mg |
| Stalevo 75 | Madopar dispersible 62.5mg |
| Stalevo 100 | Madopar dispersible 125mg |
| Stalevo 125 | Madopar dispersible 125mg |
| Stalevo 150 |
Madopar dispersible 125mg plus Madopar dispersible 62.5mg |
| Stalevo 200 | Madopar dispersible 125mg x 2 |
The above is an initial rough guide for changing to Madopar dispersible. Madopar dispersible will give a higher peak dose and a shorter duration of action. The number of doses per day may need to increase to compensate for stopping the entacapone component e.g change from 4 hourly spacing to 3 hourly if Parkinson's symptoms increase before the next dose. If excess dyskinesia reduce the dose and give more often (eg change Madopar dispersible 125mg x 2 given 4 hourly to Madopar 125mg given 3 hourly).
Entacapone (invariably prescribed in addition to Levodopa)
If on Sinemet plus separate entacapone tablets or Madopar plus entacapone prescribe the Sinemet or Madopar doses as Madopar dispersible (dose equivalent as in table). Use the same timings as prior to admission, withhold entacapone and seek advice once in working hours as dose timings may need to be brought closer together.
Section 2 – Dopamine agonist medications (ropinirole and pramipexole and cabergoline)
Ropinirole
| Ropinirole Prolonged Release tablets. Do NOT crush or give via NG tube. Convert to the equivalent dose of short acting ropinirole Divide daily prolonged release dose by 3 to give nearest equivalent tds dose. | Short acting ropinirole Can be crushed and mixed with water for administration via Ng tube or crushed and given with water +/- thickener or soft food Max dose 24mg Space evenly eg 8am, 2pm and 8pm | Rotigotine equivalent dose (if NG not possible) |
| 2 – 4mg | 1mg tds | 2mg |
| 5 - 6mg | 2mg tds | 4mg |
| 7 – 9mg | 3mg tds | 6mg |
| 10 – 12mg | 4 mg tds | 8mg |
| 13 - 15mg | 5mg tds | 10mg |
| 16 – 18mg | 6mg tds | 12mg |
| 19 – 21mg | 7mg tds | 14mg |
| 22 – 24mg | 8mg tds | 16mg |
Pramipexole
| Pramipexole Prolonged Release once daily. Do NOT crush or give via NG tube. Convert to short acting pramipexole or rotigotine patch (NB Pramipexole can be prescribed as either base or salt – the doses differ) | Short acting pramipexole equivalent dose Can be crushed and mixed with water (+/- thickener) or given via NG tube Give three times a day eg 8am, 2pm and 8pm | Rotigotine equivalent dose (if NG not possible) |
| 0.26mg (base) 0.375mg (salt) | 88mcg tds (base) | 2mg |
| 0.52mg (base) 0.75mg (salt) | 180mcg tds (base) | 4mg |
| 1.05mg (base) 1.5 mg (salt) | 350mcg tds (base) | 6mg |
| 1.57mg (base) 2.25mg (salt) | 350mcg plus 180mcg given together tds (base) | 8mg |
| 2.10 mg (base) 3.0 mg (salt) | 700mcg tds (base) | 10mg |
| 2.62mg (base) 3.75mg (salt) | 700mcg plus 180mcg given together tds (base) | 12mg |
| 3.15mg (base) 4.5 mg (salt) | 700mcg plus 350mcg given together tds (base) | 16mg |
Cabergoline
If taking cabergoline, convert to rotigotine patch. Do not crush or give via NG
| Cabergoline | Rotigotine equivalent dose |
| 0.5mg | 2mg |
| 0.5mg | 2mg |
| 1mg | 4mg |
| 2mg | 6mg |
| 3mg | 8mg |
| 4mg | 12mg |
| 5mg | 16mg |
| 6mg | 16mg |
Section 3 – Apomorphine pumps
Apomorphine (Apo-go) subcut infusion – This should only be instigated under the guidance of a PD specialist. It is not suitable for emergency administration in a drug-naïve patient. If a patient already on apomorphine is admitted this can be continued – contact Pulteney ward nursing staff for advice regarding setting up the pump (including during out of hours).
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