Greater Glasgow and Clyde Medicines

Parkinson’s Disease and Palliative Care

Management of palliative patients with Parkinson’s disease (PD) approaching end of life who are normally maintained on oral PD medicines

Issues to consider:

  • Administration of PD medicines when the oral route is no longer available
  • Choice of anticipatory medicines in patients with PD

Plan for loss of the oral route

  • A plan should be proactively put in place in advance and discussed with the patient, their family, and the PD and palliative care specialists.
  • If the patient loses oral route and:
    • Nasogastric (NG) tube in situ – continue to administer suitable formulation of usual medicines via NG.
    • NG tube not in situ or displaced - prescribe an appropriate dose of rotigotine patch.

Seek advice from pharmacist or PD specialist or follow GGC PD Nil By Mouth Guidance until PD specialist review.

 

Choice of anticipatory medicines in patients with PD
If a patient is in the last weeks or days of life, prescribe ‘just in case’ (JIC) anticipatory medication for end of life symptom control – see below for appropriate choices:

  • Nausea and vomiting
    • The choice of anti-emetics is often complex. Anti-emetics that block D2 (dopamine) receptors should generally be avoided. When selecting an anti-emetic careful consideration is needed, balancing risk versus benefit in discussion with specialists.
    1. Cyclizine: is often used first line in practice. It is a relatively broad spectrum anti-emetic and as a H1 receptor antagonist it is not as high risk as other anti-emetics.
    2. Levomepromazine: may be used ONLY after discussion with PD and palliative care specialists. It blocks D2 receptors however, has lower affinity for D2 than some other anti-emetics.
    3. Other antiemetics suitable for PD patients:
      Ondansetron: use in palliative care is limited and it is likely to be less effective than alternatives as anticipatory medication
      Domperidone: is not available in injectable form and therefore is not an appropriate choice for anticipatory medication
    4. Avoid: metoclopramide, haloperidol, prochlorperazine. These medicines have a very high risk of worsening PD symptoms as they block D2 receptors.
  • Agitation/restlessness
    1. Midazolam: should be used first line, as per Scottish Palliative Care Guidelines.
    2. Levomepromazine: as above - may be used ONLY after discussion with PD and palliative care specialists.
    3. Avoid: haloperidol as it blocks D2 receptors.

 

Refer to PD nurse specialist and palliative care team if needed. See Adult Therapeutics Handbook-Appendix 6 for contact numbers of PD specialists.

Other blogs in the PD series include:

 

Published 07/05/2021. Updated 02/02/22 with new links and again 13/09/23. Medicines Update blogs are correct at the time of publication.

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