4.4.2 – Parkinson’s disease

Related guidance: Parkinson’s disease in adults NICE guideline (NG71 July 2017)

Orthostatic hypotension due to autonomic dysfunction: midodrine Evidence summary (ESNM61

Dementia: assessment, management and support for people living with dementia and their carers NICE guideline (NG97 June 2018)

Parkinson’s disease medicines formulations for adults with swallowing difficulties (SPS June 2022)

Emergency management of patients with Parkinson’s (Parkinson’s UK November 2013)

See Somerset NHS Foundation Trust Dietetics service.

See NHS Somerset formulary feed thickeners.

See NHS Somerset specials guidance.

  • Communication with people with Parkinson’s disease should aim towards empowering people to participate in judgements and choices about their own care with an aim to achieve a balance between providing honest, realistic information about the condition and promoting a feeling of optimism. Because people with Parkinson’s disease may develop impaired cognitive ability, communication problems and/or depression, provide them with and record both oral and written communication throughout the course of the disease, which should be individually tailored and reinforced as necessary with consistent communication from professionals involved.
  • Advise family members and carers about their right to carer assessment and assessment for respite care and other support. See the NICE guideline on supporting adult carers for recommendations on identifying, assessing and meeting the caring, physical and mental health needs of families and carers.
  • People with Parkinson’s disease should have a comprehensive care plan agreed between the person, their family members and carers and specialist healthcare providers, offered an accessible point of contact with specialist services and advised to inform the Driver and Vehicle Licensing Agency (DVLA) and their car insurer of their condition when Parkinson’s disease is diagnosed.
  • Suspect Parkinson’s disease in people presenting with tremor, stiffness, slowness, balance problems and/or gait disorders. If Parkinson’s disease is suspected, refer people quickly and untreated to a specialist with expertise in the differential diagnosis of this condition.
  • The diagnosis of Parkinson’s disease must be regularly reviewed and reconsidered if atypical clinical features develop.
  • Offer levodopa to people in the early stages of Parkinson’s disease whose motor symptoms impact on their quality of life and consider a choice of dopamine agonists, levodopa or monoamine oxidase B (MAO-B) inhibitors for people in the early stages of Parkinson’s disease whose motor symptoms do not impact on their quality of life. Ergot-derived dopamine agonists should not be offered as first-line treatment for Parkinson’s disease.
  • Parkinson’s medication should be prescribed at specific times and administered on time. NPSA alert 2010 highlighted people with Parkinson’s disease who do not receive their medicines on time may recover slowly or lose function, such as ability to walk.
  • Abrupt withdrawal or failure due to poor absorption (for example, gastroenteritis, abdominal surgery) should be avoided due to the potential for acute loss of movement or neuroleptic malignant syndrome and should be adjusted only after discussion with a specialist in the management of Parkinson’s disease.
  • Swallowing difficulties may develop and can be unpredictable and variable. Advice should be sought from the Parkinson’s Disease specialist team where possible, particularly for changes to complex medication regimens with a rescue plan in place to prioritise dopaminergic and other essential medication during this period. Some formulations can be crushed if needed, see SPS guidance. Dispersible Co-beneldopa is a useful option during swallowing difficulties and can be used with thickener as per Speech and language therapist (SALT) advice, it has a faster onset and shorter duration of action. Transdermal dopamine agonist may be considered if oral route is no longer reliable to avoid acute loss of movement or neuroleptic malignant syndrome.
  • Impulse control disorders (e.g. compulsive gambling, hypersexuality, binge eating and obsessive shopping) can develop in a person with Parkinson’s disease who is on any dopaminergic therapy at any stage in the disease course. Dopamine agonist therapy, history of previous impulsive behaviours and a history of alcohol consumption and/or smoking increases this risk. Refer to specialist as therpay may need to be modified. Specialist cognitive behavioural therapy targeted at impulse control disorders may be offered if modifying dopaminergic therapy is not effective.
  • Dopamine agonists may cause excessive day time sleepiness. Advise people not to drive and to inform the DVLA of their symptoms and consider any occupation hazards. Refer to specialist for medication adjustment to reduce occurrence.
  • Patients may experience psychotic symptoms (hallucinations and delusions) with all Parkinson’s disease treatments (higher risk with dopamine agonists). Refer to specialist if person is experiencing hallucinations (particularly visual) or delusions as medication may need to be modified. Do not treat hallucinations and delusions if they are well tolerated by the person with Parkinson’s disease and their family members and carers. Quetiapine may be considered by specialist to treat hallucinations and delusions in people with Parkinson’s disease who have no cognitive impairment. If standard treatment is not effective, clozapine may be offered to treat hallucinations and delusions in people with Parkinson’s disease. Be aware that registration with a patient monitoring service is needed and that lower doses of quetiapine and clozapine are needed for people with Parkinson’s disease than in other indications. Olanzapine should not be used to treat hallucinations and delusions in people with Parkinson’s disease. Antipsychotic medicines (such as phenothiazines and butyrophenones) can worsen the motor features of Parkinson’s disease.
  • For hallucinations and delusions in people with dementia, conduct a structured assessment to explore possible reasons for their distress and check for and address clinical or environmental causes (e.g. pain, delirium or inappropriate care) before starting non-pharmacological or pharmacological treatment. As initial and ongoing management, offer psychosocial and environmental interventions to reduce distress in people living with dementia. Only offer antipsychotics for people living with dementia who are either at risk of harming themselves or others or experiencing agitation, hallucinations or delusions that are causing them severe distress.
  • A cholinesterase inhibitor such as rivastigmine or donepezil, galantamine and rivastigmine patches (off-label) may be offered by a specialist for people with mild or moderate Parkinson’s disease dementia. Consider a cholinesterase inhibitor for people with severe Parkinson’s disease dementia (off-label) and memantine (off-label) only if cholinesterase inhibitors are not tolerated or are contraindicated. For guidance on assessing and managing dementia, and supporting people living with dementia, see the NICE guideline on dementia. See NHS Somerset Shared Care Protocol for Dementia.
  • If a person with Parkinson’s disease has developed dyskinesia and/or motor fluctuations, including medicines ‘wearing off’, seek advice from specialist before modifying therapy. Dopamine agonists, MAO-B inhibitors or catechol-O-methyl transferase (COMT) inhibitors may be offered as an adjunct to levodopa for people with Parkinson’s disease who have developed dyskinesia or motor fluctuations despite optimal levodopa therapy. If dyskinesia is not adequately managed by modifying existing therapy, amantadine may be considered. Do not offer anticholinergics to people with Parkinson’s disease who have developed dyskinesia and/or motor fluctuations.
  • Care should be taken to identify and manage restless leg syndrome and rapid eye movement sleep behaviour disorder in people with Parkinson’s disease and sleep disturbance. Please refer to specialist.
  • Melatonin is a useful option for Parkinson’s disease related insomnia on the recommendation of secondary care see Traffic light guidance as of benefit to elderly patients at risk of falling, or to people who drive and are susceptible to next-day drowsiness of z-drugs and benzodiazepines, in addition avoidance of associated dependance and withdrawal. See NICE’s guideline on medicines associated with dependence or withdrawal symptoms. See NHS Somerset formulary sleep disorders.
  • Refer to specialist for the management of nocturnal akinesia and orthostatic hypotension as a review of existing medicines including antihypertensives (including diuretics), dopaminergics, anticholinergics and antidepressants may be required. Non-pharmacological management options are recommended first-line for orthostatic hypotension include compression stockings, blood pressure monitoring and increased water and salt ingestion. Midodrine may be considered second line, taking into account the contraindications and monitoring requirements (including monitoring for supine hypertension). NHS Somerset classify Midodrine as an Amber drug see Traffic light guidance.
  • For guidance on identifying, treating and managing depression in people with Parkinson’s disease, see  NICE’s guideline on depression in adults with a chronic physical health problem and NHS Somerset formulary antidepressants. Fluoxetine would not be considered a first line option in people with Parkinson’s disease when starting an antidepressant as may impact on future Parkinson’s disease medication options e.g. increased risk of serotonin syndrome if taken in combination with MAOIs e.g. Rasagiline and Selegiline and atypical antipsychotics e.g. quetiapine and clozapine.
  • Only consider pharmacological management for drooling of saliva in people with Parkinson’s disease if non-pharmacological management e.g. speech and language therapy is not available or has not been effective. Consider glycopyrronium bromide to manage drooling of saliva in people with Parkinson’s disease. Only consider anticholinergic medicines e.g. hyoscine hydrobromide other than glycopyrronium bromide to manage drooling of saliva in people with Parkinson’s disease if their risk of cognitive adverse effects is thought to be minimal. Topical preparations can be considered to reduce the risk of adverse events e.g. Hyoscine patch (off-label) or atropine eye drops (off-label and non-formulary). If these treatment options are not effective, not tolerated or contraindicated e.g. in people with cognitive impairment, hallucinations or delusions, or a history of adverse effects following anticholinergic treatment consider referral to a specialist service for botulinum toxin A. NHS Somerset classify botulinum toxin A as a Red drug, see Traffic light guidance.
  • Do not use vitamin E, co-enzyme Q10, dopamine agonists, or MAO-B inhibitors as a neuroprotective therapy for people with Parkinson’s disease.
  • Constipation often affects those with Parkinson’s disease due to improper functioning of the autonomic nervous system, responsible for regulating smooth muscle activity which can result in the intestinal tract operating slowly. The normal length of time between bowel movements ranges widely from person to person. Some people have bowel movements three times a day; others only one to two times a week. Going longer than three days without a bowel movement causes the stool to harden and become more difficult to pass.The most common causes include:
    • not eating enough fibre, which is found in fruits, vegetables and cereals
    • not drinking enough fluids
    • not moving enough and spending long periods sitting or lying down
    • being less active and not exercising
    • often ignoring the urge to go to the toilet
    • changing your diet or daily routine
    • a side effect of medicine e.g. anticholinergics
    • stress, anxiety or depression
  • If you are caring for someone with dementia, constipation may be easily missed. Look out for any behaviour changes, as it might mean they are in pain or discomfort.
  • See The Association of UK Dieticians Feeling bunged up? Don’t let poo be a taboo and See NHS Somerset formulary constipation.
  • Domperidone should be considered first line if an anti-emetic is needed. See Somerset NHS formulary Nausea and labyrinth disorders. Metoclopramide should be avoided due to extrapyramidal effects and cyclizine used with caution due to potential extrapyramidal and anti-cholinergic effects.

People who continue treatment should be reviewed regularly by specialist in the management of Parkinson’s disease.

 

 

 

 

 

 

 

 

Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Dopaminergic drugs
Levodopa with decarboxylase inhibitorsCo-beneldopa (Levodopa/Benserazide)
Immediate release12.5/50mg capsule: £4.96 (100)
25/100mg capsule: £6.91 (100)
50/200mg capsule: £11.78 (100)
Modified release25/100mg capsule: £12.77 (100)Modified release is not levodopa equivalent
See Parkinson’s UK Calculate Adjusted Levodopa Equivalent Daily Dose
Dispersible12.5/50mg tablet: £5.90 (100)
Dispersible has a faster onset and shorter duration of action.
50/100mg tablet: £10.45 (100)
Co-careldopa (Levodopa/Carbidopa)
Immediate release12.5/50mg tablet: £3.37 (90)
10/100mg tablet: £13.98 (100)
25/100mg tablet: £5.87 (100)
25mg/250mg tablet: £35.23 (100)
Modified release25/100mg tablet:£11.60 (60)
50/200mg tablet: £11.60 (60)
Modified release is not levodopa equivalent
See Parkinson’s UK Calculate Adjusted Levodopa Equivalent Daily Dose
Catechol-o-methyltransferase inhibitorsEntacapone200mg tablet: £3.07 (30)Maximum 2g daily.
NHS Somerset classify as an Amber drug as per Traffic light guidance
Opicapone50mg capsule: £93.90 (30)Maximum 50mg daily.
NHS Somerset classify as an Amber drug as per Traffic light guidance
NHS Somerset classify Tolcapone as a Red drug (specialist prescribing only) as per Traffic light guidance
Levodopa with catechol-o-methyltransferase inhibitorLevodopa/ Carbidopa/ Entacapone
as Sastravi or Stanek®
50mg/12.5mg/200mg tablet: £10.35 (30) £34.66 (100) Maximum 10 tablets per day.
75mg/18.75mg/200mg tablets: £10.35 (30) £34.66 (100)
100mg/25mg/200mg tablets: £10.35 (30) £34.66 (100)
125mg/31.25mg/200mg tablets: £10.35 (30) £34.66 (100)
150mg/37.5mg/200mg tablets: £10.35 (30) £34.66 (100)
175mg/43.75mg/200mg tablets: £10.35 (30) £34.66 (100) Maximum 8 tablets per day.
200mg/50mg/200mg tablets: £10.35 (30) £34.66 (100) Maximum 7 tablets per day.
Dopamine receptor agonistsAmantadine100mg capsule: £13.67 (56)
10 mg per 1 ml oral solution sugar free: £140 (150ml)
NHS Somerset classify as an Amber drug as per Traffic light guidance
Maximum 400mg daily.
Ropinirole
Immediate release
250 mcg tablet: £3.99 (12)Maximum 24mg daily.
500 mcg tablet: £7.08
1 mg tablet: £49.84 (84)
2 mg tablet: £19.14
5 mg tablet: £214.25 (84)
Modified release2 mg tablet: £12.54
4mg tablet: £25.09
6mg tablet: £15.32
8mg tablet: £42.11
Pramipexole
Immediate release
88 mcg tablet: £2.10 (30)Maximum 3.3 mg base daily.
180 mcg tablet : £1.49 (30)
350 mcg tablet: £15.03 (30)
700 mcg tablet: £1.80 (30)
Modified release260 mcg tablet: £30.81 (30)Maximum 3.15 mg base daily.
520 mcg tablet: £60.11 (30)
1.05 mg tablet : £119.76 (30)
1.57 mg tablet: £191.90 (30)
2.1 mg tablet: £246.46 (30)
2.62 mg tablet: £312.10 (30)
3.15 mg tablet: £369.71 (30)
NHS Somerset classify Cabergoline as a Red drug (specialist prescribing only) as per Traffic light guidance
Rotigotine2 mg per 24 hour transdermal patch: £81.10 Maximum 16mg daily.
Apply the patch to a different place on your skin every day – use the body map as a guide to locate appropriate areas to place the patch.
4 mg per 24 hour transdermal patch: £123.60
6 mg per 24 hour transdermal patch: £149.93
8 mg per 24 hour transdermal patch: £149.93
NHS Somerset classify Apomorphine as a Red drug (specialist prescribing only) as per Traffic light guidance
Monoamine oxidase B inhibitorsRasagiline1mg tablet: £3.81 NHS Somerset classify as an Amber drug as per Traffic light guidance

Maximum 1mg daily.
Selegiline5mg tablet: £16.52 (100)NHS Somerset classify as an Amber drug as per Traffic light guidance

Maximum 10mg daily.
Safinamide is classified by NHS Somerset as a Black drug (Not
recommended) as per Traffic light guidance
Sympathomimetic- VasoconstrictorMidodrine2.5mg tablet: £28.73 (100)
5mg tablet: £41.66 (100)
10mg tablet: £83.32 (100)
NHS Somerset classify as an Amber drug for orthostatic hypotension as per Traffic light guidance
The usual initial dosage is 2.5 mg, 2-3 times daily (every 3-4 hours). The dose should be increased at weekly intervals in small increments until an optimal response is obtained (max 30 mg/day) and taken during daytime when the person performs daily activities in upright position. The last dose should be taken at least four hours before bedtime to reduce the risk of supine hypertension. Blood pressure in supine and sitting position should be regularly monitored at the beginning of the treatment (at least twice a week). Treatment should be stopped if supine hypertension is significantly excessive.