Updating Hospital Policies to Improve Inpatient Care for Patients With Parkinson Disease

Introduction

Worsening of disease manifestations in patients with Parkinson disease (PD) undergoing hospital care negatively impacts patient outcomes due to complications such as aspiration and falls.¹ In a mini-review published in Frontiers in Pharmacology, the authors identify and discuss approaches to improve outcomes for patients with PD undergoing hospital care. These approaches center on administering levodopa-carbidopa medications in a timely manner, limiting substitutions or omissions of patient’s PD medications, and avoiding medications that worsen PD.¹

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Levodopa-Carbidopa Dosing Intervals

Levodopa-carbidopa therapy is the mainstay for treating PD despite its short half-life requiring administration up to 4 times a day.² Levodopa is converted to dopamine in the brain and overcomes the dopamine deficit observed in patients with PD.³ Patients usually follow the pharmacists’ instructions to administer levodopa-carbidopa at specified intervals to limit problems such as wearing off due to delayed administration or dyskinesias due to premature administration.⁴ To limit these issues, hospital systems should ensure that these dosing intervals are maintained when outpatients with PD are hospitalized.¹

Most hospitals rely on electronic medical records (EMRs) and nursing medication administration records (MARs) to administer medications to inpatients. Hospital pharmacists should ensure that levodopa-carbidopa’s dosing times are entered correctly in EMRs and MARs (e.g., 4 times daily is not recorded as every 6 hours).¹ By speaking with patients directly, using patient safety kits (e.g., Parkinson’s Foundation Aware in Care kit),⁵ or accessing outpatient office visit notes and dispensing records, hospital pharmacists can also ensure that dosing intervals in EMRs/MARs match the patient’s schedule in the outpatient setting.¹ The authors recommend that hospital pharmacists have access to these records for patients with PD.¹

Hospital staff should label levodopa-carbidopa as “time-critical” in EMRs and MARs to ensure that the medication is administered within 30 minutes before or after the scheduled administration time.¹ To facilitate “time-critical” administration, the authors recommend that hospitals either use automated dispensing cabinets (ADCs) or dispense 24-hour supply of levodopa-carbidopa to the nursing staff.¹ If delays in administration occur (intentional or otherwise), hospitals should have procedures in place to notify the prescriber to update MARs for administration of subsequent doses.¹

Since levodopa is transported into the blood/brain by amino acid carrier proteins, hospital meal services should provide high protein meals 60 minutes after the most recent dose of levodopa-carbidopa to allow for maximum absorption/transport of levodopa.¹

Limit Medication Substitution and/or Omission

Levodopa-carbidopa is available in several different formulations that are not therapeutically equivalent due to differences in their safety, efficacy, and pharmacokinetic profiles.^6,7 Hospital administration should ensure that all levodopa-carbidopa formulations are on the formulary, stocked, and hospital staff is trained to recognize the different formulations.¹ If not feasible, hospital pharmacists should borrow the necessary formulation from a nearby hospital or identify, relabel, and use patient-owned supplies during their hospital stay.¹ Only if none of these approaches are viable should the hospital pharmacists substitute another formulation that delivers equivalent dose of levodopa.¹

For patients having difficulty swallowing, experiencing nausea/vomiting, or those on nil per os or nothing per orem (NPO) status, hospitals should stock and use oral disintegrating tablets or inhalation formulations of levodopa-carbidopa, rotigotine transdermal patch, or sublingual/subcutaneous formulations of apomorphine rather than omitting a dose.¹ For patients who are sedated or mechanically ventilated, nurses should administer an equivalent dose of crushed levodopa-carbidopa immediate-release tablets via nasogastric tubes.¹

In all cases, trained professionals should design and implement the equivalent dose of levodopa between formulations.

Avoid Medications that Worsen PD Symptoms

The authors recommend that hospitals remove drugs with dopamine receptor blocking activity from standard, perioperative, and postoperative order sets for patients with PD undergoing surgery.¹ Hospital staff should avoid ADC overrides to acquire dopamine receptor antagonists commonly used for controlling emesis, agitation, or psychotic episodes in patients with PD.¹ These drugs worsen mobility problems and aggravate swallowing difficulties, and therefore lead to poor outcomes in patients with PD.¹ Hospital pharmacists should note EMR alerts if providers order dopamine receptor antagonists for patients with PD and recommend alternatives (e.g., ondansetron to control emesis, benzodiazepines to control agitation, and dopamine antagonists least likely to cause motor issues to control psychotic episodes).¹

Conclusion

Hospitals need to optimize their policies on several fronts to improve outcomes for patients with PD undergoing hospital care. Hospital pharmacists can play an important role in advocating for, designing, and implementing these policies.

About the Author

Alok Sharma is a Professor of Pharmaceutical Sciences at Massachusetts College of Pharmacy and Health Sciences in Manchester, New Hampshire.

References

1. Yu JRT, Sokola BS, and Walter BL (2023). Optimization of inpatient medication administration among persons with Parkinson’s disease: recommendations on pharmacy technology and workflow. Front. Pharmacol. 14:1254757. doi: 10.3389/fphar.2023.1254757

2. UCSF Health Conditions & Treatments: Parkinson’s Disease. Accessed December 14, 2023. https://www.ucsfhealth.org/conditions/parkinsons-disease

3. Mayo Clinic Drugs and Supplements: Carbidopa and Levodopa (Oral Route). Accessed December 14, 2023. https://www.mayoclinic.org/drugs-supplements/carbidopa-and-levodopa-oral-route/description/drg-20095211

4. SINEMETâ (carbidopa-levodopa) tablets. Accessed January 11, 2024. https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/017555s069lbl.pdf

5. Parkinson’s Foundation Resources and Support: Hospital Safety Guide. Accessed December 15, 2023. https://www.parkinson.org/resources-support/hospital-safety-guide

6. Davis Phinney Foundation for Parkinson’s: An Overview of Levodopa Formulations. Accessed December 21, 2023. https://davisphinneyfoundation.org/levodopa-formulations/

7. Livingston C, Monroe-Duprey L. A Review of Levodopa Formulations for the Treatment of Parkinson's Disease Available in the United States. J Pharm Pract. 2023 Jan 27:8971900221151194. doi: 10.1177/08971900221151194. Epub ahead of print. PMID: 36704966.