Parkinson’s Disease (PD) and Elective Surgery
Management of Parkinson’s disease (PD) medicines in patients undergoing elective surgery who are normally maintained on oral PD medicines
Issues to consider:
- Advanced surgical planning including early referral to PD nurse specialist. See contact details within GGC Adult Therapeutics Handbook (Appendix 6)
- Potential post-operative complications
Advanced surgical planning/pre-operative assessment:
- Patients with PD can develop worsening of symptoms, and in some cases there is an increased risk of developing neuroleptic malignant like syndrome, if doses of medicines are delayed or missed.
- It is important to formulate an individualised peri-operative medicines plan for these patients with the relevant members of the multi-disciplinary team (MDT) and discuss this with the patient. Early referral to PD nurse specialists (at pre-assessment clinic) is recommended. It is particularly important to contact the PD specialist if the patient is likely to be nil by mouth (NBM) for longer than 6 hours as alternative PD medicines may be required.
- It is important to maintain the patient’s PD medicine regimen and to ensure continuation of PD medicines as close to the time of surgery as possible. Placing patients with PD first on the surgical operating list allows greater predictability of operation time therefore minimising the potential risk of a prolonged NBM period. Resume PD medicines as soon as it is safe post surgery.
- If patients are on selegiline or rasagiline for PD this will require careful planning prior to surgery. Selegiline and rasagiline are monoamine oxidase –B inhibitors and may interact with medicines that are indicated during surgery. There is an increased risk of hypertensive crisis when given with drugs such as noradrenaline, metaraminol or dobutamine. There is a risk of hypotension when given with some anaesthesia. In some cases, it may be appropriate to withhold selegiline or rasagiline for 2 weeks prior to surgery to avoid any potential interactions. This should be discussed with the anaesthetist and PD specialists prior to surgery. A safe time frame for restarting selegiline or rasagiline post surgery should also be considered.
- Advise patients to bring a supply of their own medicines when admitted for surgery.
Potential post-operative complications
- Nausea and vomiting:
- Refer to GGC Adult Therapeutics Handbook-Parkinson's disease in Acute Care. If persistent emesis occurs, refer to GGC PD Nil by Mouth Guidance (on StaffNet).
- Avoid metoclopramide and prochlorperazine as dopamine blockers can be associated with worsening of PD symptoms.
- Cyclizine, domperidone and ondansetron can be used. Caution: ondansetron and domperidone can prolong QTc and ondansetron can cause constipation.
- The use of selegiline or rasagiline along with ondansetron can increase the risk of serotonin syndrome. If concurrent use cannot be avoided monitor patient for symptoms and stop concurrent use if serotonin syndrome occurs.
- Use non-opioid medicines if possible. If opioid analgesics are needed check the BNF for cautions, contraindications and interactions.
- There may be an increased risk of serotonin syndrome when selegiline or rasagiline is used with some opioids including fentanyl, tramadol and pethidine. Concurrent use should be avoided.
- Constipation/delayed gastric emptying:
- Refer to GGC Adult Therapeutics Handbook-Parkinson's disease in Acute Care and to GGC Therapeutics Handbook- Management of Constipation.
- Constipation/delayed gastric emptying may interfere with how well PD medicines are absorbed making them less effective.
- Monitor bowel function, review medicines that may precipitate constipation and prescribe or adjust laxatives as appropriate. Seek advice from PD specialist if necessary.
- Refer to Management of Acutely Disturbed Patients including Delirium guideline and blog Delirium: Medication Review in Acute.
- Investigate and treat underlying cause (e.g. medicine induced infection, pain, electrolyte imbalance, dehydration, constipation). Always try non-pharmacological management first.
- Avoid management with medications that block dopamine receptors e.g. haloperidol.
- Enteral feeding tubes:
- Contact ward pharmacist or PD nurse specialist for advice regarding PD medicines administration via enteral feeding tubes as this can affect medicine choice, formulation and absorption.
- Out of hours, refer to GGC PD Nil by Mouth Guidance (on StaffNet) or contact on-call pharmacist for advice.
Published: 31/03/2021. Medicines Update blogs are correct at the time of publication.