Clinical pearls: Perioperative Management of Parkinson’s Disease
May 9, 2022
By Bhawani Jain
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Parkinson’s Disease (PD) is a progressive neurodegenerative disease that leads to a variety of motor and non-motor symptoms such as tremors, slowing in movement (i.e. bradykinesia), muscle rigidity, dementia, and progressive autonomic dysfunction, among many other clinical features.1,2 It is the second-most common disease worldwide, after Alzheimer’s disease.3 The prevalence of PD increases with age and predominantly affects adults above 60 years of age.1,4 In Canada, the average age of onset of PD is 64.4 years with a diagnosis at 66.2 years. In 2013-2014, about 84000 Canadians over 40 years of age were living with PD with a 1.5-fold greater prevalence in males compared to females.4
People over the age of 65 with PD are about 1.45 times more likely to have an unplanned admission to hospital than those over 65 without PD and have longer hospital stays and readmission rates.5 There are multiple reasons for hospitalizations among patients with PD, and these include motor complications due to PD (i.e. falls, fractures), co-morbid complications (pneumonia, cardiac issues, genitourinary infections, cancer, stroke), elective surgery, and other reasons.6
Important Considerations for Patients with PD Having Surgery
Patients with PD use antiparkinsonian medications to manage their symptoms and prevent worsening of their condition. It is important for these patients to take their antiparkinsonian medications as prescribed and on time because delays in timing and abrupt withdrawal of medication can lead to a worsening of motor symptoms that do not recover.7 This can significantly impact patient safety, treatment, quality of life, and duration of stay in the hospital. It is important for hospital pharmacists to ensure that a thorough medication review is completed when a patient with PD is admitted to hospital for elective surgery. These patients should continue taking their medications up to the time of surgery and immediately after surgery to prevent complications of PD and worsening of symptoms.8 If a patient with PD is having elective surgery, it is important that a best possible medication history (BPMH) is completed, (with an emphasis on timing of their antiparkinsonian medications) prior to surgery to ensure the same medications can be ordered promptly for continuity of care. Some patients with PD may have difficulty swallowing, so they may require liquid forms of medications or other dosage forms.8 Knowing this beforehand is important because unique dosage forms of certain medications may not be readily available beforehand and may need to be ordered in advance to prevent delays in receiving PD therapy in hospital.
Patients with PD undergoing surgery are at risk of complications such as aspiration pneumonia, post-operative respiratory failure, and neuroleptic malignant syndrome.9 Since muscle rigidity is a common symptoms in those with PD, the orofacial muscles can be affected as well. This causes oropharyngeal dysphagia, or difficulty swallowing. Due to this, patients with PD become at risk of aspiration pneumonia which causes up to 70% of deaths among deaths due to complications of PD.10,11 Furthermore, abrupt discontinuation or delayed continuation of antiparkinsonian medications can precipitate neuroleptic malignant syndrome which is a potentially lethal neurological emergency characterized by hyperthermia, altered consciousness, changes in mental status, and further autonomic dysfunction.12,13 As such, it is important to reduce the risks of complications. It is generally recommended that the PD therapy the patient receives in the hospital resembles the patient’s usual treatment regimen as closely as possible.9 Patients who take the oral combination of carbidopa and levodopa and are having a long surgery can be given the same medication via a nasogastric tube during surgery so that the patient doesn’t experience delays in the timing of PD therapy.14 In patients with PD who are expected to experience delayed gastric emptying, post-operative ileus, or other conditions that make enteral medication inappropriate, switching the patient’s medications to a parenteral medication may be required, and this may be a different medication entirely.9 Knowing the possible alternatives to PD medications available in the hospital will be beneficial for the patient’s recovery in hospital, especially if the patient is admitted to the hospital due to an emergency or urgent surgery in which case communicating with the patient before admission was not possible.
Drug Interactions with Antiparkinsonian Medications
Since patients with PD are typically of advanced age, it is common for these patients to have co-morbid conditions and require medication for these conditions. As such, it is important for hospital pharmacists to be aware of drug interactions between antiparkinsonian medications and other medications to ensure that the patient’s therapy for PD is not being hindered.
Table 1: A Non-exhaustive List of Drug Interactions for Common Antiparkinsonian Medications and their Mechanism for Interaction.2,15,16,17
After surgery, many patients require new medications. Patients may also require antibiotics post-surgery or due to acquiring nosocomial infections in the hospital. Furthermore, many patients experience side effects due to their antiparkinsonian medications such as nausea, vomiting, orthostatic hypotension, dyskinesias, hallucinations, confusion, and other effects.2
These patients may also require medication to manage these side effects. Due to these considerations, it is important to assess whether a new medication is appropriate for the patient while also not affecting the patient’s current therapy to manage PD.
Antiparkinsonian Medications and Dosage Forms Available in Canada
Table 2: A Non-Exhaustive List of Antiparkinsonian Medications, Dosage Forms, and Details Available in Canada2, 15, 17-23
Communicating with Patients Living with PD
It is important to understand that patients with PD are all unique and there are a wide range of clinical presentations and symptoms of varying progression and disability. This makes it crucial to ensure that the hospital environment and therapy supports the patient and is unique to their needs. For instance, some patients with PD may experience difficulties with communication such as slurring of speech and a quiet voice.24 In this case, it may be important for a patient to have their caregiver or loved one close by to assist with communication. Having a healthcare professional who is specialized in neurodegenerative disease and movement disorders (nurse, doctor, etc.) in the patient’s healthcare team would be very beneficial as well.25
- Chou KL. Clinical manifestations of Parkinson disease. UpToDate [Internet]. 03 March 2022 [cited 21 April 2022].
- Parkinson Disease | CPS [Internet]. Canadian Pharmacists Association. 21 April 2021 [cited 21 April 2022].
- Ou Z, Pan J, Tang S, et al. Global Trends in the Incidence, Prevalence, and Years Lived With Disability of Parkinson's Disease in 204 Countries/Territories From 1990 to 2019. Front Public Health. 2021;9:776847. Published 2021 Dec 7. doi:10.3389/fpubh.2021.776847
- Parkinsonism in Canada, including Parkinson's Disease, Highlights from the Canadian Chronic Disease Surveillance System. Public Health Agency of Canada. Health Canada. 10 April 2018 [cited 21 April 2022]. Available from: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/parkinsonism.html
- Chou KL, Zamudio J, Schmidt P, et al. Hospitalization in Parkinson disease: a survey of National Parkinson Foundation Centers. Parkinsonism Relat Disord. 2011;17(6):440-445. doi:10.1016/j.parkreldis.2011.03.002
- 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(3):139-145. doi:10.1016/j.parkreldis.2010.11.009
- Grimes D, Fitzpatrick M, Gordon J, et al. Canadian guideline for Parkinson disease. CMAJ. 2019;191(36):E989-E1004. doi:10.1503/cmaj.181504
- Merli GJ, Bell RD. Perioperative care of the surgical patient with neurologic disease. UpToDate [Internet]. 13 April 2022 [cited 21 April 2022].
- Brennan KA, Genever RW. Managing Parkinson's disease during surgery. BMJ. 2010;341:c5718. Published 2010 Nov 1. doi:10.1136/bmj.c5718
- Won JH, Byun SJ, Oh BM, Park SJ, Seo HG. Risk and mortality of aspiration pneumonia in Parkinson's disease: a nationwide database study. Sci Rep. 2021;11(1):6597. Published 2021 Mar 23. doi:10.1038/s41598-021-86011-w
- Mehanna R, Jankovic J. Respiratory problems in neurologic movement disorders. Parkinsonism Relat Disord. 2010;16(10):628-638. doi:10.1016/j.parkreldis.2010.07.004
- Keyser DL, Rodnitzky RL. Neuroleptic malignant syndrome in Parkinson's disease after withdrawal or alteration of dopaminergic therapy. Arch Intern Med. 1991;151(4):794-796.
- Velamoor VR. Neuroleptic malignant syndrome. Recognition, prevention and management. Drug Saf. 1998;19(1):73-82. doi:10.2165/00002018-199819010-00006
- Stagg P, Grice T. Nasogastric medication for perioperative Parkinson's rigidity during anaesthesia emergence. Anaesth Intensive Care. 2011;39(6):1128-1130. doi:10.1177/0310057X1103900623
- Lexicomp Online, Interactions. Waltham, MA: UpToDate, Inc.; https://online.lexi.com. Accessed April 21, 2022.
- Pahwa R, Swank S. Medications, A Treatment Guide to Parkinson’s Disease. Parkinson’s Foundation. ©2020. Accessed April 21, 2022. Available from: https://www.parkinson.org/sites/default/files/attachments/Medications-Treatment-Guide-to-Parkinsons-Disease.pdf
- Gilbert R. Medications To Be Avoided Or Used With Caution in Parkinson’s Disease. American Parkinson Disease Association. March 2018. Accessed April 21, 2022. Available from: https://www.apdaparkinson.org/wp-content/uploads/2018/05/APDA-Meds_to_Avoid.pdf
- Health Canada. Drug Product Database Online Query. Ottawa, ON: Health Canada; [cited 20 Dec 2019]. Available from: http://webprod5.hcsc.gc.ca/dpd-bdpp/index-eng.jsp
- Parkinson's Treatment. “Tips & Pearls”. June 2005. Objective Comparisons for Optimal Drug Therapy. The RxFiles Academic Detailing Program. Available from www.rxfiles.ca.
- Pharmacoeconomic Review Report for Safinamide (Onstryv). CADTH Common Drug Review. May 2020.
- Parsitan®. Prescribing Information Product Monograph. ERFA Canada 2012 Inc. November 26 2022.
- Duodopa®. Product Monograph. AbbVie Corporation. February 23 2018.
- Prolopa®. Product Monograph. Hoffmann-La Roche Limited. August 06 2019.
- Street C, Frost K. Key information for hospital pharmacists. Parkinsons.org.uk. UK Parkinson’s Excellence Network. Updated in 2018. Accessed April 21, 2022. Available from: https://www.parkinsons.org.uk/sites/default/files/2019-03/Key%20information%20for%20hospital%20pharmacists%20online.pdf
- Mathur S, Dautsch H. Managing My Parkinson’s Disease in Healthcare Settings. Parkinson Canada. © 2018. Accessed April 21, 2022. Available from: https://www.parkinson.ca/wp-content/uploads/Managing-My-Parkinsons-Disease-in-Healthcare-Settings.pdf