Rationalising drugs for Parkinson disease in palliative care
Follow the principles of medication rationalisation when rationalising drugs for Parkinson disease.
In patients with palliative care needs, the aim of anti-Parkinson therapy is to prevent severe rigidity and decrease pain while minimising agitation. Patient response to anti-Parkinson therapy can change over time—regularly review and titrate dose.
Anti-Parkinson therapy is usually continued until death; avoid missing doses to optimise symptom control and avoid dopaminergic withdrawal syndrome. However, some patients may develop increased adverse effects or loss of efficacy, and may need anti-Parkinson therapy to be ceased and replaced with subcutaneous midazolam or sublingual clonazepam to manage rigidity.
Patients with Parkinson disease usually eventually lose the ability to swallow—make a plan to ensure continuation of therapy.
When patients who take oral anti-Parkinson therapy can no longer swallow, the approach to drug administration depends on whether they have an enteral feeding tube. Regardless, seek expert advice if possible before changing therapy, particularly for patients with fragile disease control (eg those who need to take levodopa every 2 to 3 hours). When changing therapy, it is important to avoid precipitating agitation, hallucinations and delirium (if the dose is too high), or re-emergence of Parkinson signs (if the dose is too low). To facilitate changing therapy, the patient’s total daily doses of oral anti-Parkinson therapy is converted to levodopa equivalent doses (LEDs). A conservative dose conversion tool is recommended to determine dosing in patients with palliative care needs—see PD ‘Nil by Mouth’ Medication Dose Calculator.
Consider prescribing as-required doses of dispersible Madopar (benserazide+levodopa) for breakthrough therapy when switching formulations, if the patient can tolerate these.
For patients with an enteral feeding tube, switch oral drug formulations to formulations that can be administered via the tube1.
For patients who do not have an enteral feeding tube, consider switching to transdermal rotigotine. Ideally, start the switch before swallowing deteriorates. Start the rotigotine patch at 2 mg/24 hours, and increase by 2 mg/24 hours at weekly intervals (to a maximum of 8 mg/24 hours in early stage Parkinson disease, and 16 mg/24 hours in advanced stage Parkinson disease) while decreasing doses of oral formulations. The optimal rotigotine dose will be determined by the patient’s symptoms. If loss of swallow occurs quickly, an immediate switch to rotigotine patch is needed; determine the starting dose of rotigotine patch using the PD ‘Nil by Mouth’ Medication Dose Calculator.
For principles of palliative care for patients with Parkinson disease, see Principles of palliative care for patients with Parkinson disease.