Issues for surgery
Risk of exacerbation of Parkinson’s disease (PD) and akinesia if omitted.
Risk of Dopamine Agonist Withdrawal Syndrome (DAWS) if omitted (see Further information).
Risk of QT-interval prolongation if continued (see Interactions with common anaesthetic agents and Interactions with other common medicines used in the perioperative period).
Advice in the perioperative period
Elective and emergency surgery
Continue.
Post-operative advice
Continue post-operatively at patient’s usual dose.
Interactions with common anaesthetic agents
For general information regarding the use of anaesthetic agents in PD – see Parkinson’s disease –Overview.
Hypotension
Apomorphine can increase the risk of hypotension when used concomitantly with inhalational or intravenous anaesthetics.
QT-interval prolongation
See also Interactions with other common medicines used in the perioperative period.
Apomorphine, especially at high dose, is known to cause QT-interval prolongation. Co-administration with other medicines known to prolong the QT-interval must be based on careful assessment of the potential risks and benefits for each patient.
Anaesthetic agents that may be used in the perioperative period that are known to, or predicted to, prolong the QT-interval include:
- desflurane, isoflurane, sevoflurane - avoid
- thiopental (theoretical)*
*monitor ECG with concurrent use if risk factors for QT-prolongation are also present (increasing age, female sex, cardiac disease, and some metabolic disturbances e.g. hypokalaemia)
Interactions with other common medicines used in the perioperative period
QT-interval prolongation
Apomorphine, especially at high dose, is known to cause QT-interval prolongation. Co-administration of apomorphine with other medicines known to prolong the QT-interval must be based on a careful assessment of the potential risks and benefits for each patient since the risk of torsade de pointes may increase.
Medicines that may be used in the perioperative period that are known to prolong the QT-interval include:
- ciprofloxacin*
- clarithromycin*
- domperidone – see below
- erythromycin (especially intravenous)*
- granisetron*
- loperamide (increased risk with high doses)*
- ondansetron*
*monitor ECG with concurrent use if risk factors for QT-interval prolongation also present (increasing age, female sex, cardiac disease, and some metabolic disturbances e.g. hypokalaemia)
Droperidol, haloperidol and prochlorperazine are also known to cause QT prolongation; however, these agents should not be used in PD (see Parkinson’s Disease –Overview).
Domperidone
Pre-treatment with domperidone is essential before apomorphine initiation as it is highly emetogenic; however, ECG monitoring is recommended before starting domperidone, during initiation of apomorphine and whenever clinically indicated thereafter. The ongoing use of domperidone must be carefully evaluated taking into account any patient factors, which predispose to QT prolongation.
Antiemetics
See also QT-interval prolongation above.
Concurrent use of apomorphine and ondansetron has been associated with profound hypotension and loss of consciousness; avoid concomitant use of apomorphine and ondansetron, granisetron or other 5-HT3 receptor antagonists.
Apomorphine can increase the risk of hypotension when used concomitantly with droperidol or prochlorperazine. However, these medications should be avoided in patients with PD as they exacerbate symptoms.
For general information regarding the use of antiemetics in PD – see Parkinson’s Disease –Overview.
Hypokalaemia
Dexamethasone and hydrocortisone may cause hypokalaemia; potentially increasing the risk of torsades de pointes when given with apomorphine – use with caution. If hypokalaemia occurs, corrective action should be taken and QT interval monitored.
Further information
Withdrawal
Abrupt withdrawal of dopamine agonists is associated with DAWS, which mimics Neuroleptic Malignant Syndrome (NMS).
Prescribing and administration
Access to the correct medication or formulation at the correct time remains a problem for people with PD whilst they are in hospital. Delayed doses can have serious implications. PD patients often have complex medication regimes; prescribers should take care to confirm the correct dose, formulation and time of administration with the patient or carer. The time of administration should be documented on the prescription chart and nursing staff should ensure that PD medications are given promptly.
References
National Institute of Health and Clinical Excellence (2017). NG71 Parkinson’s disease in adults. https://www.nice.org.uk/guidance/ng71 [Accessed on 9th June 2019]
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 22nd August 2019]
Summary of Product Characteristics – APO-go (apomorphine) PFS 5mg/ml Solution for Infusion in Pre-filled Syringe®. Britannia Pharmaceuticals Limited. Accessed via www.medicines.org.uk 22/08/2019 [date of revision of the text February 2018]
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 22nd August 2019]
Brennan KA & Genever RW. Managing Parkinson’s disease during surgery. BMJ. 2010; 341:c5718