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Resource spotlight: Perioperative Management of Parkinson’s Disease

May 20, 2022

 

Written by Bhawani Jain

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca


Managing Parkinson’s Disease (PD) in the hospital can be a complex process that involves a variety of factors including drug interactions, timing of PD therapy, communication issues, and seeking alternative medications during surgery. This week’s “Resource Spotlight” shows resources to help pharmacists understand PD from a clinician and patient perspective, including management of PD drug therapy.  
 

Parkinson Canada  
Parkinson Canada is the Canadian national organization for Parkinson’s Disease. This website contains a variety of resources, especially for patients to learn about PD and how to manage their symptoms. There are plenty of handouts and fact sheets for patients and clinicians about topics pertaining to PD such as “Young-Onset Parkinson's Disease: Advice for Physicians From Individuals Living With YOPD ”. One important resource is “Managing My Parkinson’s Disease in Healthcare Settings ”. Though this resource is intended for patients, clinicians and pharmacists can understand the perspective of patients with PD and can remind patients about things they should mention or bring before arriving to the hospital for elective surgery. This resource also helps pharmacists understand the roles that other health professionals have in caring for a patient with PD. This resource also has a list of some of the medications that patients should avoid taking, which is also helpful for hospital pharmacists. 

 

Canadian Guideline for Parkinson Disease  
The Canadian Guideline for Parkinson Disease, published by the Canadian Medical Association Journal, is a resource for physicians, pharmacists, and other healthcare professionals to receive updated information about PD treatment in Canada. It highlights a summary of communication recommendations, diagnosis and progression of PD, various medication and procedure treatments, and ways to manage non-motor symptoms. This guideline contains a summary of key recommendations backed by empirical evidence in all areas of PD diagnosis, management, and treatment. This resource also contains a flowchart of PD diagnosis and progression and what clinicians can do at certain stages of the patient’s progression of PD.  

 

American Parkinson Disease Association  
The American Parkinson Disease Association (APDA) is the United States national organization for PD. Like the Canadian website, there are a variety of resources for patients and clinicians. There is also information about educational webinars and current clinical trials in PD treatment. A useful resource published by the APDA is a list of “Medications To Be Avoided Or Used With Caution in Parkinson’s Disease ”. This is not an exhaustive list and only provides information for patients taking selegiline, rasagiline, or safinamide. However, it is a useful two-page resource that hospital pharmacists can quickly refer to for patients taking one of these medications so that drug interactions can be avoided.  

 

Key Information for Hospital Pharmacists - Parkinson's UK
The Parkinson’s Disease Society of the United Kingdom has published a resource specifically for hospital pharmacists. It contains information about medication considerations, managing side effects with medications while avoiding drug interactions, how to manage swallowing issues for affected patients, drugs to avoid, ensuring that patients receive their medications on time, preparation of medications before the patient is admitted to hospital, and supporting the patient to take control of their medications post-discharge. It is a helpful and comprehensive resource that hospital pharmacists can consult to know more about how to best care for a patient with PD. The Parkinson’s UK website  also contains a separate set of resources specifically for healthcare professionals such as guidelines, clinical tools, assessments, and resources that can be provided to patients.  

 

Research Articles for Perioperative Care 
There are some research articles that can be helpful for hospital pharmacists. “Managing Parkinson's disease during surgery ” is an article that focuses on preventing complications from missing dopaminergic medication during surgery for patients with PD. The article focuses on advance planning, appropriate prescribing, and specialist advice. There are also some examples of alternative enteric and non-enteric medications that can be administered to patients during surgery to prevent progression and worsening of PD while in the hospital. The American Journal of Medicine has also published a journal titled “Perioperative Management of Patients with Parkinson’s Disease ” which contains a comprehensive list of recommendations, complications that can arise, and ways they can be prevented and managed. There is also information about how post-operative pain and psychiatric issues can be treated, while avoiding medications that can worsen PD.  

 
References 
  1. Brennan KA, Genever RW. Managing Parkinson's disease during surgery. BMJ. 2010;341:c5718. Published 2010 Nov 1. doi:10.1136/bmj.c5718 
  2. Katus L, Shtilbans A. Perioperative management of patients with Parkinson's disease. Am J Med. 2014;127(4):275-280. doi:10.1016/j.amjmed.2013.11.014  
May 20, 2022
Resource spotlight: Perioperative Management of Parkinson’s Disease

Clinical pearls: Perioperative Management of Parkinson’s Disease

May 9, 2022
By Bhawani Jain

This article was written and researched by a CSHP student member for Interactions, our biweekly newsletter. Crafting these pieces not only helps students gain in-depth knowledge of specific conditions, treatments, and resources, it also helps them hone their skills in research, critical appraisal, evaluation, synthesis, and writing – all of which will serve them well in clinical practice. The Professional Practice Team works with the student to select topics that are of interest and utility to both the student and to you, the reader. We hope you enjoy this piece by one of our future colleagues! Let us know what you think: If you would like to provide any comments or constructive feedback for our students, please email us at practice@cshp.ca.

Background

 
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
 

REFERENCES 

  1. Chou KL. Clinical manifestations of Parkinson disease. UpToDate [Internet]. 03 March 2022 [cited 21 April 2022].
  2. Parkinson Disease | CPS [Internet]. Canadian Pharmacists Association. 21 April 2021 [cited 21 April 2022].
  3. 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
  4. 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
  5. 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
  6. 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
  7. Grimes D, Fitzpatrick M, Gordon J, et al. Canadian guideline for Parkinson disease. CMAJ. 2019;191(36):E989-E1004. doi:10.1503/cmaj.181504
  8. Merli GJ, Bell RD. Perioperative care of the surgical patient with neurologic disease. UpToDate [Internet]. 13 April 2022 [cited 21 April 2022].
  9. Brennan KA, Genever RW. Managing Parkinson's disease during surgery. BMJ. 2010;341:c5718. Published 2010 Nov 1. doi:10.1136/bmj.c5718
  10. 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
  11. 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
  12. 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.
  13. Velamoor VR. Neuroleptic malignant syndrome. Recognition, prevention and management. Drug Saf. 1998;19(1):73-82. doi:10.2165/00002018-199819010-00006
  14. 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
  15. Lexicomp Online, Interactions. Waltham, MA: UpToDate, Inc.; https://online.lexi.com. Accessed April 21, 2022.
  16. 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 
  17. 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
  18. 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
  19. Parkinson's Treatment. “Tips & Pearls”. June 2005. Objective Comparisons for Optimal Drug Therapy. The RxFiles Academic Detailing Program. Available from www.rxfiles.ca.
  20. Pharmacoeconomic Review Report for Safinamide (Onstryv). CADTH Common Drug Review. May 2020.
  21. Parsitan®. Prescribing Information Product Monograph. ERFA Canada 2012 Inc. November 26 2022.
  22. Duodopa®. Product Monograph. AbbVie Corporation. February 23 2018.
  23. Prolopa®. Product Monograph. Hoffmann-La Roche Limited. August 06 2019. 
  24. 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
  25. 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 

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May 08, 2022
Clinical pearls: Perioperative Management of Parkinson’s Disease

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PEBC update

April 22, 2022

The Pharmacy Examining Board of Canada recently shared updates from its Annual Board Meeting on March 26, 2022, featuring statistics from 2021 and summaries of PEBC's recent projects.

2021 by the numbers

2551 candidates took the Pharmacist Qualifying Examination-Part I (MCQ) in 2021, compared with 2162 in 2020.

2513 candidates took the Pharmacist Qualifying Examination-Part II (OSCE), compared to 975 in 2020.

1935 individuals took the Pharmacist Evaluating Examination in 2021, compared to 1827 in 2020.

2412 applicants were ruled acceptable for admission into the Evaluating Examination, compared to 2464 in 2020.

733 names were added to the Pharmacy Technician Register by examination in 2021, compared to 461 in 2020, bringing the total to 12,257 since 2009.

1180 candidates took the Pharmacy Technician Qualifying Examination-Part I (MCQ) in 2021, compared to 716 in 2020.

1136 individuals took the Pharmacy Technician Qualifying Examination-Part II (OSPE in 2021, compared to 673 in 2020. 

PEBC projects

As a result of the pandemic, PEBC committed to exploring the possibility of conducting virtual performance examinations for the OSCE and OSPE. The Board is undertaking a pilot study to explore the feasibility of the virtual format, on its own and compared to in-person exams. 

The Board is also conducting a comprehensive review of PEBC's certification processes, to identify ways to enhance the process. Recommendations will be made by an advisory committee of pharmacists, pharmacy technicians, and a physician.

 

 

April 22, 2022
PEBC update

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Call for nominations: Fellows Recognition Committee

April 21, 2022

 

The Fellows (FCSHP) Recognition Committee is now calling for nominations for one Committee Member position. Joining this committee is an exciting way to celebrate Canadian hospital pharmacy excellence. If you know an eligible CSHP member who would thrive in this role, please consider nominating them for this position! 

How long is the term?
Committee members are appointed for a three-year term and are eligible for reappointment for one additional three-year term. The term for this position begins August 2022.

Who is eligible?
Nominees must have achieved Fellow status and hold current membership in CSHP.

How can I nominate someone?
Provide a short biography or statement including information on how the nominee qualifies for the position. Nominations for the Committee must be made in writing, signed by the nominee and a nominator, and be submitted to the Chair of the Fellows Nominating Committee, using the nomination form. Nominators must also hold the FCSHP designation. Click here for details and to access the nomination form.

Deadline
All nominations must be received by May 31, 2022.
April 21, 2022
Call for nominations: Fellows Recognition Committee

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Call for applications: Members of the Education Grant Committee

April 21, 2022

 

The CSHP Foundation's Education Grant Committee is recruiting interested CSHP Members to join us! We are looking for broad geographical representation from our members. The Committee reviews submissions for CSHP Foundation education grants and provides recommendations to the Foundation Board.

The CSHP Foundation supports research and educational programs that advance pharmacy practice and patient care in hospitals and other collaborative healthcare settings.

Term of appointment for committee members:
2 years, option of 2 additional 2-year terms, 6 years maximum

Candidate criteria:
- Current CSHP member
- Experience and a keen interest in pharmacy-related educational activities.

Instructions for applicants:
Please submit the following documents by the deadline date:
- Copy of your curriculum vitae.
- One-page statement describing your past involvement with CSHP and your interest in volunteering for this position.

Submit the above noted documents to the CSHP office by e-mail to Rosemary Pantalone at rpantalone@cshp.ca

For more information on the role of  member of this Committee, please contact Miranda So (Chair, Education Grant Committee) at: Miranda.So@uhn.ca

Deadline date for applications: Tuesday, June 28, 2022

 
April 21, 2022
Call for applications: Members of the Education Grant Committee 2022

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