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Parkinson's — NBM / Missed Doses
Parkinson's medication is time-critical — doses within 30 minutes of usual times, never omitted. Abrupt withdrawal can cause parkinsonism-hyperpyrexia syndrome (rigidity, fever, raised CK — up to 20% mortality). If NBM: NG dispersible levodopa or…
Time-Critical PD Medication Pathway
The pathway
1 · Never omit
- Doses within 30 min of home times
- Flag chart time-critical
- Ask exactly what they take and when — regimens are individual
2 · NBM? Act tonight
- NG tube → dispersible co-beneldopa converted doses
- No NG possible → rotigotine patch
- There is no IV levodopa; never crush MR preparations
3 · Convert properly
- OPTIMAL calculator / trust guideline
- Convert dopamine agonists too (abrupt stop = withdrawal)
- Verify with pharmacy
4 · Safe symptom control
- Antiemetics: domperidone or ondansetron
- NEVER metoclopramide, prochlorperazine, haloperidol
- Psychosis: senior review ± quetiapine
5 · Withdrawal syndrome
- Rigidity + fever + ↑CK + fluctuating consciousness = parkinsonism-hyperpyrexia
- Restart dopaminergic therapy urgently, cooling, IV fluids, HDU/ITU
6 · Involve specialists
- PD nurse specialist / neurology next working day
- Self-administration where possible
- Document an NBM contingency plan
Drugs
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Co-beneldopa dispersible (Madopar) | Converted dose via OPTIMAL | NG/PO | Standard NBM route. Give at the patient's usual times. |
| Rotigotine patch | Converted dose (OPTIMAL) | TOP | When enteral route impossible. 24h transdermal delivery. |
| Domperidone | 10mg TDS | PO/NG | Antiemetic of choice — does not cross the blood-brain barrier. QT caution. |
| AVOID: metoclopramide / haloperidol / prochlorperazine | — | — | Dopamine antagonists — worsen Parkinson's severely. |
When to escalate
Any NBM Parkinson's patient — same-shift plan for alternative route,Rigidity + fever + raised CK after missed doses — HDU/ITU, restart dopaminergics,Swallow deteriorating — SALT + dietitian + PD team,New psychosis or severe dyskinesia — neurology/PD nurse, not antipsychotics
Reference: Parkinson's UK 'Get It On Time' / OPTIMAL calculator / NICE NG71
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