Parkinson’s Medication Transition of Care Checklist

Drug therapy regimens for Parkinson’s disease can be complex due to the need for multiple agents and patient-specific timing of administration.1 Hospitalization poses an increased risk for medication errors, with about 70% of Parkinson’s patients experiencing late or missed doses.1,2,12,13 Medication errors of particular importance include incorrect administration scheduling; medication omissions; and drug-drug and/or drug-disease state interactions.1-6,12,13 Sudden regimen changes with resultant loss of Parkinson’s symptom control can be upsetting for patients and caregivers, and may also be dangerous.1,4 Symptom breakthrough, including tremors, rigidity, confusion, and agitation, may precipitate falls, antipsychotic use, and complication-related increases in hospital length of stay.1,4,13 Abrupt medication discontinuation can lead to a neuroleptic malignant syndrome (NMS)-like condition that may be life-threatening.7-9 Patients unable to take oral medications perioperatively, or due to dysphagia, are at particularly high risk for symptom breakthrough and its complications.1,2,5,7 This chart provides suggestions for improving the safety of transitions of care in Parkinson’s disease patients. For more details on the pharmacotherapy of Parkinson’s disease management, see our Parkinson’s Disease Therapy Algorithm. For more generalized suggestions on improving transitions of care, see our Transitions of Care Checklist.

Abbreviations: COMT = Catecho-O-Methyl transferase; MAO = monoamine oxidase; NPO = nothing by mouth; OTC = over the counter; PO = oral; QHS = at bedtime; Q2H = every two hours; Q4H = every four hours; TID = three times daily

Topic/ Issue

Suggestions/ Pertinent Information

Be aware of ALL Parkinson’s disease medications a patient is taking.


Aim to perform thorough medication reconciliation within two hours of admission for all Parkinson’s patients.1

Obtain complete list of medications from patient, caregiver, and/or patient’s neurologist.1,3

Specifically ask about dosage forms and strengths.1,3

  • Clarify brand, generic, or individual meds in any combination products that might not be on formulary.
  • Keep in mind patients may be taking different dosage forms and strengths of levodopa-carbidopa at different times of day.1 For more details about available formulations, see our chart, Drugs for Parkinson’s Disease.

Specifically ask about home administration times, and timing with regard to meals.1,3,4

  • Parkinson’s meds may be taken in combination, and as often as Q4H during active hours of the day.11
  • Levodopa-carbidopa is best absorbed without food, but may be taken with a snack to decrease nausea.11


Provide timely, patient-specific medication administration.



Delays in Parkinson’s medication administration as short as 15 minutes can lead to symptom breakthrough (e.g., stiffness, tremor).14

Match to patient’s home administration schedule as closely as possible.3

  • Ensure med orders are not defaulted to standard administration times (TID, etc).3
  • Add Parkinson’s meds to the list of “time critical” drugs at your hospital if they aren’t already included.

Schedule COMT inhibitors (entacapone, tolcapone) to be given along with carbidopa/levodopa.11

Rotigotine transdermal system (Neupro) should be removed and reapplied at a consistent time each day.11


Ensure appropriate handling of NPO status.

Avoid abruptly stopping the entire Parkinson’s disease regimen due to risk for symptom breakthrough and possible development of a neuroleptic malignant-like syndrome.1,3,7,9

As long as carbidopa/levodopa is being given appropriately, temporarily holding adjunctive meds (pramipexole, amantadine, entacapone, etc) may be safe.2

On-time administration of carbidopa/levodopa is paramount due to its short half-life.10

  • Parcopa immediate-release disintegrating tablets can be used in patients with dysphagia.7
  • Rytary extended-release capsules can be opened and sprinkled onto applesauce for patients unable to swallow pills.11 Some clinicians suspend the capsule contents to permit enteral tube administration.
  • Use caution if converting from extended-release formulations to immediate release products.
    • Equivalence cannot be assured due to differences in absorption and duration of action.11

Nasogastric tube insertion may be necessary to facilitate medication administration while a patient is NPO.2,3

Encourage neurology consultation when enteral administration of Parkinson’s medications will be prolonged.1,7

  • Enteral feedings may interfere with levodopa absorption, further complicating Parkinson’s management.7,10

Neurologist expertise is needed when switching patients from oral or enteral meds to those given by other routes.1,7


Promote appropriate perioperative management.

Work closely with the surgery team to minimize Parkinson’s disease medication interruptions, and to prevent drug-drug interactions with anesthetics and other perioperative meds.3,7,9

Avoid medication interruptions whenever possible.5,7

  • Schedule surgery first thing in the morning.1,5
  • Have patient take their meds within 20 minutes of anesthesia induction with a sip of water.3,7,9
  • Patients with a nasogastric tube can receive their Parkinson’s meds Q2H intraoperatively if needed.7,9
  • Restart Parkinson’s meds as soon as possible postoperatively.3,9

Ondansetron or trimethobenzamide (for patients on apomorphine) are preferred for prevention and/or treatment of PONV.9

Avoid fentanyl, meperidine, and methylene blue in patients taking certain Parkinson’s meds (see below).5,7,9,11


Watch for drug-disease state and drug-drug interactions.



One out of every three Parkinson’s patients is ordered a contraindicated medication while hospitalized.1

Drug-disease state interactions

  • Avoid meds that block dopamine receptors, which can worsen Parkinson’s disease.
    • Droperidol, haloperidol, metoclopramide, prochlorperazine, promethazine, and risperidone.2,7,9
  • Safer alternatives include:
    • Ondansetron for nausea and/or vomiting (contraindicated for patients taking apomorphine).3,4
    • Low-dose quetiapine is commonly used and well-tolerated for acute psychosis associated with Parkinson’s disease.3,4
    • Clozapine or pimavanserin (Nuplazid) are options for Parkinson’s patients with chronic psychosis.3,4

Drug-drug interactions in patients taking MAO-B inhibitors (selegiline, rasagiline, and safinamide). Examples include:

  • Fentanyl and meperidine may precipitate serotonin syndrome, and should be avoided.7,9,11
  • Methylene blue inhibits MAO, and should be avoided due to risk of serotonin syndrome.5,11


Perform discharge medication reconciliation.


Check for formulary substitutions. Avoid confusion by discharging patients on their home Parkinson’s med regimen.

Provide patients and/or caregivers with an updated and complete medication list upon discharge.

Ensure patients have an adequate supply of their Parkinson’s medications on hand once they return home.

  • If using their own meds while hospitalized, make sure their supply is returned to them prior to discharge.


Provide patient and caregiver education.

Encourage patients and caregivers to keep an updated medication list with them at all times.4

  • Include medication and strength; dose; and time of adminsistration.4

For patients on MAO-B inhibitors (selegiline, rasagiline, safinamide), counsel them to:

  • Avoid OTC cough or cold preparations because they may contain dextromethorphan or pseudoephedrine.11
  • Avoid foods containing large amounts of tyramine (e.g., fermented beverages; aged cheeses; and cured, smoked, or pickled foods).11 Combining these foods with an MAO-B inhibitor can cause dangerous increases in blood pressure.11

Provide patients with contact information for the National Parkinson Foundation (NPF):


Project Leader in preparation of this clinical resource (330920): Leslie Gingo, PharmD, BCPS, Assistant Editor

References

  1. Delayed administration and contraindicated drugs place hospitalized Parkinson’s disease patients at risk. Acute Care ISMP Medication Safety Alert! March 12, 2015. https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=103. (Accessed July 31, 2017).
  2. Derry CP, Shah KJ, Caie L, Counsell CE. Medication management in people with Parkinson’s disease during surgical admissions. Postgrad Med J 2010;86:334-7.
  3. Aminoff MJ, Christine CW, Friedman JH, et al. Management of the hospitalized patient with Parkinson’s disease: current state of the field and need for guidelines. Parkinsonism Relat Disord 2011;17:139-45.
  4. National Parkinson Foundation. Chou K, Okun MS, Fernandez HH, et al. Five frequently asked questions about hospitalization for patients with Parkinson disease. Summer 2007. http://www.parkinson.org/sites/default/files/5-hospitalization-questions.pdf. (Accessed July 31, 2017).
  5. Lee LA, Meyer TA. Anesthetic drugs may interact with medications used for Parkinson’s disease. APSF Newsletter. October 2015. http://www.apsf.org/newsletters/html/2015/Oct/05_Parkinsons.htm. (Accessed July 31, 2017).
  6. National Parkinson Foundation. Aware in care hospital action plan. http://www.awareincare.org/wp-content/uploads/2016/12/Hospital-Action-Plan_2016.pdf. (Accessed July 31, 2017)
  7. Quinn R. How should Parkinson’s disease be managed perioperatively? The Hospitalist. June 2010. http://www.the-hospitalist.org/hospitalist/article/124294/how-should-parkinsons-disease-be-managed-perioperatively. (Accessed July 31, 2017).
  8. Anon. A practical guide to stopping medicines in older people. BPJ 2010;27:10-23. http://www.bpac.org.nz/BPJ/2010/April/docs/bpj_27_stop_guide_pages_10-23.pdf. (Accessed July 31, 2017).
  9. Bonnici A, Ruiner CE, St-Laurent L, Hornstein D. An interaction between levodopa and enteral nutrition resulting in neuroleptic malignant-like syndrome and prolonged ICU stay. Ann Pharmacother 2010;44:1504-7.
  10. Shaikh SI, Verma H. Parkinson’s disease and anesthesia. Indian J Anesth 2011;55:228-34.
  11. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; 2017. http://www.clinicalpharmacology.com (Accessed August 4, 2017).
  12. Gerlach OH, Winogrodzka A, Weber WE. Clinical problems in the hospitalized Parkinson’s disease patient: systematic review. Mov Disord 2011;26:197-208.
  13. Martinez-Ramirez D, Giugni JC, Little CS, et al. Missing doses and neuroleptic usage may prolong length of stay in hospitalized Parkinson’s disease patients. PLoS One 2015;10:e0124356.
  14. Parkinson’s Disease Foundation. Going to the hospital with Parkinson’s: how to be prepared. Fall 2012. http://www.pdf.org/sites/default/files/newsletters/NL_fall_12.pdf. (Accessed August 17, 2017).

Cite this document as follows: Clinical Resource, Parkinson’s Disease Medication Transition of Care Checklist. Pharmacist’s Letter/Prescriber’s Letter. September 2017.

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