Issues for surgery
For Parkinson’s disease (PD) - risk of exacerbation of PD and akinesia if omitted.
For restless legs – loss of effect if omitted.
Risk of Dopamine Agonist Withdrawal Syndrome (DAWS) if omitted (see Further information).
Advice in the perioperative period
Elective and emergency surgery
Continue.
EXCEPT:
- If patient is undergoing magnetic resonance imaging (MRI) or cardioversion, Neupro® (rotigotine) patch should be removed to avoid skin burns as the backing layer of the patch contains aluminium; for PD patients seek advice from patient’s specialist.
Post-operative advice
If removed for MRI / cardioversion, resume 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
Rotigotine can increase the risk of hypotension when used concomitantly with inhalational or intravenous anaesthetics.
Interactions with other common medicines used in the perioperative period
Antiemetics
Rotigotine 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.
Further information
Dopamine Agonist Withdrawal Syndrome (DAWS)
Abrupt withdrawal or tapering of dopamine agonists is associated with DAWS, which mimics Neuroleptic Malignant Syndrome (NMS). Symptoms include apathy, anxiety, depression, nausea, fatigue, orthostatic hypotension, sweating and pain, which may be severe. Patients should be informed about this before tapering the dopamine agonist and monitored regularly thereafter. In case of persistent symptoms, it may be necessary to increase the dopamine agonist dose temporarily.
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
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 10th August 2019]
Brennan KA & Genever RW. Managing Parkinson’s disease during surgery. BMJ. 2010; 341:c5718
Chambers DJ. Sebastian J. and Ahearn DJ. Parkinson’s disease. BJA Education. 2017; 17:145-149
Faculty of Public Health, The Royal College of Surgeons of Edinburgh, The Royal College of Anaesthetists, ash (action on smoking and health). Joint Briefing: Smoking and surgery. April 2016. Available at www.rcoa.ac.uk [Accessed 10th August 2019]
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 10th August 2019]
National Institute of Health and Clinical Excellence (2017). NG71 Parkinson’s disease in adults. https://www.nice.org.uk/guidance/ng71 [Accessed on 6th June 2019]
Summary of Product Characteristics – Neuopro® (rotigotine) 2mg/24h Transdermal Patch. UCB Pharma Limited. Accessed via www.medicines.org.uk 10/08/2019 [date of revision of the text June 2018]