UK Clinical Pharmacy Association


Issues for surgery

Risk of exacerbation of Parkinson’s disease (PD) and akinesia if omitted.

Risk of Parkinsonism-hyperpyrexia syndrome (PHS) if omitted (see Further information).

Risk of hypotension if continued (see Interactions with common anaesthetic agents).

Advice in the perioperative period

Elective and emergency surgery 

Continue (including combination products).

Combination products:

  • Stalevo® contains levodopa + carbidopa + entacapone (also see Catechol-o-methyltranseferase (COMT) inhibitors drug records)

To minimise disruption to the patient’s usual medication regime, oral levodopa with DDI medications can be given with a sip of water up until anaesthetic induction. Duodopa® intestinal gel can be continued for as long as the patient is permitted to take fluids by mouth.

Due to the short half-life of levodopa it may be necessary to site a naso-gastric tube (NGT) during prolonged procedures to enable administration of further doses (of soluble co-beneldopa) – for advice on equivalent doses see or refer to in-house guidelines where appropriate.

If a long nil by mouth (NBM) period is anticipated post-operatively the patient’s specialist should be contacted pre-operatively for advice on alternative routes or medications.

Post-operative advice

Oral levodopa and Duodopa® intestinal gel should be restarted post-operatively, at the patient’s usual dose, as soon as oral intake of fluid is allowed.

If a long NBM period is anticipated or if there are concerns regarding enteral absorption, alternative routes or medications should be considered (see Further information).

Interactions with common anaesthetic agents

For general information regarding the use of anaesthetic agents in PD – see Parkinson’s Disease –Overview.


Levodopa preparations can increase the risk of hypotension when used concomitantly with inhalational or intravenous anaesthetics.


The manufacturers advise caution with concomitant administration of co-beneldopa and sympathomimetics (e.g. epinephrine/adrenaline, norepinephrine/noradrenaline) as their action may be potentiated. Dose reduction and monitoring of cardiovascular adverse effects is advised. No recommendation is made regarding other sympathomimetics e.g. ephedrine, metaraminol, phenylephrine.

Interactions with other common medicines used in the perioperative period


Cyclizine may decrease the absorption of levodopa; however, this is unlikely to be clinically significant, as cyclizine is generally considered useful in patients with PD.

Levodopa preparations 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.

Iron supplements

Iron forms chelation complexes with levodopa and carbidopa leading to a reduced bioavailability and possible worsening of symptoms; this appears to be clinically significant in some patients. Iron and levodopa administration should be separated as much as possible and the patient monitored for deterioration in symptoms.

Further information

Parkinsonism-hyperpyrexia syndrome (PHS)

Abrupt withdrawal of levodopa can result in PHS. It is most common in individuals with severe Parkinson’s symptoms or on larger doses of levodopa. Symptoms mimic those of neuroleptic malignant syndrome and include muscle rigidity, fever, cardiovascular instability, profuse sweating and altered mental status (agitation, delirium, and coma). PHS carries a significant mortality, up to 20% in untreated cases.

NBM period and alternative routes

If there is significant post-operative nausea and vomiting, post-operative ileus or concerns about enteral absorption, the oral route is likely to be unreliable and may lead to suboptimal treatment and potentially PHS. Alternative routes or medications should be considered – see Parkinson’s Disease –Overview.

Patients who do not rapidly regain the ability to take their usual PD medication should be seen by a PD specialist nurse or movement disorder consultant at the earliest opportunity.

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.


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Chambers DJ. Sebastian J. and Ahearn DJ. Parkinson’s disease. BJA Education. 2017; 17:145-149

Summary of Product Characteristics – Sinemet Plus® (levodopa with carbidopa) 25mg/100mg Tablets. Merck Sharp & Dohme Limited. Accessed via 06/06/2019 [date of revision of the text May 2019]

Summary of Product Characteristics – Madopar® (levodopa with benserazide) 100mg/25mg Hard Capsules. Roche Products Limited. Accessed via 06/06/2019 [date of revision of the text March 2016]

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