Managing a patient with Parkinson disease who is nil-by-mouth

It is good practice for patients with Parkinson disease to take antiparkinson therapy regularly and avoid missing doses. However, expert opinion is that a patient with good control can miss two or three doses of oral antiparkinson therapy if necessary. Patients who will miss more than two or three doses of oral therapy (eg after abdominal surgery, after a stroke) should be changed to a nonoral route. For example, rotigotine patches can be applied the night before surgery and used until the patient can resume oral therapy.

Patients with fragile disease control (eg they need to take levodopa every 2 to 3 hours) who need to be nil-by-mouth should have their antiparkinson therapy changed to a nonoral route. Caution is advised—these patients are more likely to have problems when converting from oral therapy, and the consequences can be grave (eg losing control of symptoms, dopaminergic withdrawal syndrome).

Note: Seek expert advice if possible before changing the route of antiparkinson therapy, particularly for patients with fragile disease control.

Seek expert advice if possible before changing the route of antiparkinson therapy, particularly for patients with fragile disease control.

One approach to switching from oral to transdermal antiparkinson therapy is described here. It is based on the concept of levodopa equivalent doses (LEDs). An LED is the dose of antiparkinson drug that produces the same symptom control as 100 mg immediate-release levodopa combined with a dopa-decarboxylase inhibitor. The conversion factors in Converting doses of oral antiparkinson drugs to rotigotine patches are from a systematic review of studies reporting LEDs¹—these are only a guide, as comprehensive dose equivalence studies are lacking.

Convert the patient's total daily doses of levodopa and/or pramipexole to LEDs by multiplying each drug's dose by the conversion factor in Converting doses of oral antiparkinson drugs to rotigotine patches. Add the results to get the patient's total daily dose expressed as LEDs. Then divide the total daily LED by the conversion factor for rotigotine, which is 30, and round down to the nearest patch strength—this is the target dose.

Variability in patient response to rotigotine patches means there is a risk of adverse effects, even when the target patch strength has been calculated. Unless the patient has fragile disease control, consider starting rotigotine at a lower patch strength than the target dose, then titrate as tolerated to the effective dose.

Closely monitor patients who have been converted to rotigotine patches in case further dose adjustment is necessary.

Table 1. Converting doses of oral antiparkinson drugs to rotigotine patches
[NB1]
Printable table
*Step 1. Calculate total daily levodopa equivalent dose (LED) [NB2]*
Antiparkinson drug [NB3]	Total daily dose (mg)	Conversion factor [NB4]	LED (mg)
levodopa+benserazide/carbidopa		x 1
modified-release levodopa+benserazide/carbidopa		x 0.75
pramipexole		x 100
modified-release pramipexole		x 100
		Total daily LED [NB5] =
*Step 2. Convert total daily LED to target rotigotine dose*
= ............. mg rotigotine/24 hours Round down to the nearest rotigotine patch / combination of patches—this is the target dose [NB6] Maximum daily dose of rotigotine is 16 mg/24 hours
Note: NB1: Seek expert advice if possible before changing the route of antiparkinson therapy, particularly for patients with fragile disease control. NB2: A levodopa equivalent dose (LED) is the dose of drug that produces the same symptom control as 100 mg immediate-release levodopa combined with a dopa-decarboxylase inhibitor. NB3: Seek expert advice if the patient is taking an antiparkinson drug that is not listed (eg amantadine, entacapone, rasagiline, ropinirole, selegiline). NB4: Conversion factors are only a guide, as comprehensive dose equivalence studies are lacking. NB5: If total daily LED is more than 480 mg, seek expert advice. The patient may need apomorphine subcutaneously or levodopa+carbidopa intestinal gel. NB6: Unless the patient has fragile disease control, consider starting rotigotine at a lower patch strength than the target dose, then titrate as tolerated to the effective dose.

¹ Tomlinson CL, Stowe R, Patel S, Rick C, Gray R, Clarke CE. Systematic review of levodopa dose equivalency reporting in Parkinson's disease. Mov Disord 2010;25(15):2649-53. [URL]Return