About PD and swallowing difficulties
Advice should be sought from the patient’s Parkinson’s Disease specialist team where possible, particularly for changes to complex medication regimens.
People with Parkinson’s disease are at increased risk of swallowing difficulties; their swallow status should be recorded on any referral for hospital admission.
Dose administration schedules are tailored to the individual patient to manage their symptoms. The Parkinson’s UK ‘Get it on time’ campaign highlights the importance of administering Parkinson’s disease medicines at the right time for people in in care homes or hospital.
Interaction between PD medicines and food
The manufacturer of Madopar recommend it is given on an empty stomach as levodopa absorption can be reduced if taken with a protein-rich meal. However in practice, any effect on absorption will be stable as long as medicines are given consistently in the same way (with a snack, meal or on an empty stomach).
If switching from taking on an empty stomach to taking with food, monitor for effects and adjust the dose accordingly if necessary.
Licensed medicines in suitable formulations
Amantadine 50mg/5ml oral solution
Available as a licensed preparation. It does not require fridge storage and has an expiry of 30 days after opening.
Co-beneldopa (Madopar) dispersible tablets
The manufacturer recommends Madopar dispersible tablets are dispersed in at least 25ml water or diluted orange squash per tablet.
Switching
If switching from co-careldopa (Sinemet, Sinemet CR, Half Sinemet, Half Sinemet CR, Sinemet Plus tablets) or other co-beneldopa preparations (Madopar or Madopar CR capsules), continue the same total daily levodopa dose. If switching from other preparations, there are two online calculators that can be used, alongside clinical reasoning, to determine the levodopa-equivalent dose of the patient’s medicines, allowing patients to be switched to an appropriate dose of Madopar dispersible tablets.
Monitor the patient and adjust the dose if necessary, according to response.
Rotigotine patch
Once-daily patch available in various strengths.
Switching
There are two online calculators that can be used, alongside clinical reasoning, to determine the levodopa-equivalent dose of the patient’s medicines, and then a further conversion factor to find the appropriate strength rotigotine patch(es). If possible, seek advice from the patient’s specialist Parkinson’s disease team.
Monitor the patient and adjust the dose if necessary, according to response.
Licensed medicines used in an unlicensed manner
Due to potential changes in bioavailability, patients should be monitored and doses adjusted according to response when any of the following licensed medicines are used in an unlicensed way (e.g. crushing).
Amantadine capsules
Can be opened and the contents mixed with water or soft food. A licensed oral solution is available.
Bromocriptine tablets
Can be crushed and dispersed in water or given with soft food.
Cabergoline tablets
Can be crushed and mixed with water or soft food.
Co-beneldopa (Madopar) dispersible tablets –with food
They are only licensed for administration with water or orange squash (not orange juice), however they can be crushed and given with soft food, as long as method of administration is consistent (see above)
Co-beneldopa (Madopar) capsules
Madopar immediate-release capsules can be opened and the contents mixed with water or soft food. The capsule contents are reported to taste bitter.
Note: co-beneldopa prolonged-release capsules are NOT suitable for opening. Patients can be switched to the same total daily dose of immediate-release capsules or dispersible tablets.
Co-careldopa (Sinemet, Half Sinemet) tablets
Sinemet immediate-release tablets can be dispersed in water or mixed with soft food.
Note: Co-careldopa prolonged-release tablets should are NOT suitable for crushing. Patients can be switched to the same total daily dose of immediate-release tablets, or to Madopar dispersible tablets.
Entacapone tablets
Can be crushed and mixed with water, orange juice or soft food. The tablets are film-coated and may taste bitter.
Entacapone + co-careldopa (Sastravi / Stalevo) tablets
Can be crushed and mixed with water, orange juice or soft food.
Pramipexole tablets
Immediate-release tablets can be crushed and mixed with water.
Note: pramipexole prolonged-release (Mirapexin PR) tablets are NOT suitable for crushing. Patients can be switched to the same total daily dose of immediate-release pramipexole.
Rasagiline tablets
Can be crushed and mixed with water or soft food.
Ropinirole tablets
Immediate-release tablets can be crushed and/or dispersed in water or crushed and given with soft food. They are film-coated so may taste bitter.
Note: ropinirole modified-release (Ipinnia XL) tablets are NOT suitable for crushing. Patients can be switched to the same total daily dose of immediate-release ropinirole.
Selegiline tablets
Can be dispersed in water or crushed and mixed with soft food.
Tolcapone tablets
Can be crushed and mixed with water or soft food. They are film-coated so may taste bitter.
Special-order medicines
The following preparations are listed in Part VIIIB of the Drug Tariff:
Co-careldopa 12.5mg/50mg/5ml and 25mg/100mg/5ml oral suspensions