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.
114 HHE 2018 | hospitalhealthcare. com