in detail to the patient starting treatment . NICE is clear that surgery for Parkinson ’ s should not be offered as initial or early treatment .
Late disease As the condition progresses , adverse effects of therapy generally emerge in the form of fluctuation in response , involuntary fidgety movements ( dyskinesia ) and psychotic ideation . Eventually , treatment-resistant symptoms dominate the clinical picture . 6 Treatment of more advanced disease can be clinically challenging , and the guideline recognises that there are many treatment options to be considered . These include :
• Apomorphine , a drug in solution given by intermittent subcutaneous bolus injection or infusion under the skin using a small wearable pump
• Deep brain stimulation using implanted electrodes and a battery driver – surgery is usually provided in the regional specialist neurosurgical centre
• Clozapine for patients who cannot tolerate dopaminergic drug treatments because they develop psychotic symptoms such as hallucinations and paranoia .
NICE ’ s detailed economic analysis examined a further option for advanced Parkinson ’ s , that of levodopa – carbidopa intestinal gel ( Duodopa ® ). This involves infusing levodopa directly into the gut jejunum so as to ensure constant delivery of the drug via the bloodstream to the brain . However , it was so far from being cost-effective that NICE determined it should not be offered . At present there is a conflict between the NHSE commissioning policy on Duodopa 7 ( which is that it should be offered in particular circumstances , and was drawn up before NICE ’ s evaluation was published ) and this recommendation from NICE in the current Parkinson ’ s guideline .
Treatment of complications of Parkinson ’ s There are some specific problems that require expert management in people with Parkinson ’ s , and some drugs are used which are not commonly otherwise prescribed in primary care , and which therefore may challenge clinical systems which rely on prescribing these in primary care :
• Excessive sleepiness is common in those with Parkinson ’ s and may represent a risk for driving . If this symptom is troublesome , the guideline recommends consideration of the drug modafinil , which then requires regular monitoring by a specialist .
• Rapid eye movement sleep behaviour disorder is characterised by abnormal movements during sleep , often associated with vivid dreaming , which may be violent . NICE recommends consideration of clonazepam or melatonin for this condition .
• Orthostatic hypertension ( drop of blood pressure on standing ) is a common problem in Parkinson ’ s , worsened by medication . It may require adjustment of medication and the use of the unusual hypertensive agent , midodrine .
• Drooling may require treatment with the anticholinergic drugs , but the compounds commonly used for this problem ( for example , when associated with cerebral palsy ) such as
hyoscine or atropine may readily provoke confusion and hallucinations in those with Parkinson ’ s . Glycopyrrolate , a drug that does not readily cross the blood – brain barrier , is specifically recommended by NICE , because it is less likely to precipitate hallucinations , but the drug is not well known or readily available in primary care in the UK .
• Use of the dopaminergic drugs bromocriptine or cabergoline is relatively unusual in the UK , but some clinicians see that these drugs have specific benefits for patients with advanced disease . These drugs can potentially cause fibrotic reactions in the lung , peritoneum , pleura and heart valves , and patients on these drugs therefore need regular blood tests and echocardiography .
• Dementia is common as the disease advances . NICE ’ s recommendations of cholinesterase inhibitors for this problem is in line with accepted practice in Alzheimer ’ s disease and other dementias , 8 and nowadays poses no particular problems in primary or secondary care , though the support for carers of patients with dementia in the community may be very challenging .
• Palliative care for patients with end-stage disease is recommended . Palliative care teams may be resistant to accepting such referrals as they may be commissioned principally for the management of malignant disease . 9
General practitioners may feel that prescribing these drugs is beyond their competence or remit in primary care . It may be that local secondary care services have to draw up shared care agreements with primary care to clarify the prescribing roles and responsibilities for these drugs .
6 HHE 2018 | hospitalhealthcare . com