GGC Medicines


Adult Therapeutics Handbook

Parkinson's Disease in Acute Care

Parkinson's Disease in Acute Care

Introduction

This guidance highlights the importance of continuing Parkinson's disease (PD) medication and covers the first-line management of PD patients who have:

  • Nil by mouth status
  • Confusion / hallucination / agitation
  • Dizziness and falls
  • Nausea and vomiting

Assessment / monitoring

It is crucial not to stop PD drugs for any significant length of time i.e. >2 hours or to miss any doses as there is a risk of Neuroleptic Malignant-Like Syndrome (Parkinson hyperpyrexia syndrome, PHS) which may be fatal. Symptoms include rigidity, pyrexia, and reduced conscious level. There may be features of autonomic instability, and serum creatine kinase (CK) may be elevated. Complications of PHS include acute renal failure, aspiration pneumonia, deep venous thrombosis / pulmonary embolism and disseminated intravascular coagulation.

General management

Where a patient does not have an individual supply of their PD medication, access supplies via the pharmacy or the local main holding areas of PD medications across NHSGGC. A full list of the PD medicines available in holding areas across NHSGGC sites is available on StaffNet, Clinical guideline electronic resource directory, search in the 'central nervous section' for "NHSGGC Parkinson's disease PD medication stock list across acute hospitals". It is important for PD medications to be administered at exact times. This should be clearly annotated on the prescription chart.

Table 1 - Location of PD medicines across acute NHSGGC hospitals

Site Location
Gartnavel General Hospital Emergency drug cupboard
Glasgow Royal Infirmary Ward 39
Inverclyde Royal Hospital Larkfield Unit ward 2
Queen Elizabeth University Hospital Ward 55 (Langlands) and emergency drug cupboard (based in ARU)
Royal Alexandra Hospital Ward 5
Victoria Infirmary NVH wards 1 and 2
Vale of Leven Ward 14
Mental health sites Contact pharmacy or on-call pharmacist for a supply (see Appendix 6 for contact details)

If PD medicine is not available as above, contact pharmacy or on-call pharmacist (out of hours) for a supply.

Inform PD nurse specialist of all PD patient admissions (see Appendix 6 for contact details)

Drug therapy / treatment options

Nil by mouth patients

Refer to PD specialist (see Appendix 6 for contact details). If PD specialist is not available please refer to the 'Nil by mouth medicines for Parkinson's disease in the acute setting' guidance on StaffNet, Clinical Guideline Electronic Resource Directory, and search in the 'Central nervous system' section.

Advice can also be sought from a clinical pharmacist, Medicines Information (see Appendix 6 for contact details) or on-call pharmacist (out of hours) regarding alternative formulations.

Confusion / hallucination / agitation

  • Only if necessary treat with benzodiazepine.
  • Avoid first generation antipsychotics e.g. haloperidol or chlorpromazine.
  • Refer to Management of Acutely Disturbed Patients, including Delirium.
  • Refer to PD specialist for assessment as soon as possible.

Dizziness and falls

  • Review need for drugs which precipitate postural hypotension or affect cardiac function e.g. anti-hypertensives, heart failure drugs, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, anticholinergics, acetylcholinesterase inhibitors.
  • PD medications and PD itself may be associated with orthostatic hypotension (check standing BP).
  • Refer to PD specialist for assessment as soon as possible.

Nausea and Vomiting

  • Use domperidone oral 10mg every 8 hours. Use for the shortest duration possible. The maximum duration should not usually exceed one week.
    • Caution: Domperidone is associated with a risk of cardiac side effects. See www.mhra.gov.uk (April 2014) for further information on contraindications. Avoid with other QT prolonging drugs or potent CYP3A4 inhibitors (see www.crediblemeds.org for further details). Consider alternatives in at risk patients.
  • Cyclizine oral/IM/IV 50mg every 8 hours (in elderly use 25mg) or ondansetron (unlicensed use) are also appropriate.
    • Note: Ondansetron may prolong QT interval and may cause / worsen constipation. Use with caution.
  • Avoid metoclopramide and prochlorperazine.

    Note: Exercise clinical judgement on the applicability of this guidance to individual PD patients depending on their characteristics. Both risk and benefit should be considered, seek advice from senior if unsure.

Subcutaneous Apomorphine (for infusion)

  • All patients admitted to hospital on apomorphine should be referred to the PD nurse specialist, movement disorders team or pharmacist for advice as soon as possible (see Appendix 6 for contact details).
  • An NHSGGC monograph for maintaining apomorphine subcutaneous infusion treatment in patients admitted to hospital is available on StaffNet, Clinical Guideline Electronic Resource Directory and search in 'Central nervous system' section for 'Subcutaneous Apomorphine (for infusion)'.
  • Apomorphine should only be instigated with the guidance of a prescriber experienced in PD (it is not suitable for emergency administration in a drug naive patient). If a patient is already established on this then it must be continued.

Co-careldopa intestinal gel (Duodopa)

  • Co-careldopa intestinal gel should only be instigated under specialist guidance and following the completion of the appropriate approval processes.
  • It is not suitable in an emergency situation as it requires the insertion of a percutaneous endoscopic gastrostomy with jejunal (PEG-J) tube.
  • If a patient is already established on it then it must be continued. Refer to the PD nurse specialist or the Movement Disorder team as soon as possible. The duodopa support helpline can be contacted (see Appendix 6 for contact details) if a PD specialist is not available e.g. out of hours.