Parkinson’s disease
NICE NG71: Parkinson’s disease
Prescribing Notes:
- The optimal regimen depends on several factors such as age, cognitive state, nature and stage of disease.
- It is not possible to identify a universal first choice drug therapy for either early PD or for adjuvant drug therapy for later PD.
- When choosing drug treatment, take into account clinical and lifestyle preferences and patient preference (after informing them of short and long-term benefits and disadvantages of the different drug classes).
- Specialist advice should precede initiation of drug therapy.
- Older patients are more susceptible to adverse drug effects, and thus treatment should be initiated at low doses, and increased with caution.
- Dopamine agonists, and less commonly levodopa, may cause impulse control disorders (pathological gambling/shopping, hypersexuality). Patients and carers should be advised in advance of these potential adverse effects. If the patient develops an impulse control disorder, contact specialist teams to discuss advice for titrating downwards slowly, until the symptoms resolve or are manageable in the context of their overall motor control.
- Patients with PD should be encouraged to take their medication regularly, and this is particularly relevant in situations where they are not self-medicating (e.g. hospital admission). Medication regimens should only be adjusted after discussion with a specialist.
- Not all strengths of drugs for Parkinson’s disease are stocked in hospital pharmacies. Patients should be advised to bring in their own medication when being admitted to ensure continuity of treatment. In situations where patients do not bring medication, other formulations of medication can be given to cover unavailability, advice should be sought from Parkinson’s specialists.
- If a patient develops dyskinesia or motor fluctuations, specialist advice should be sought before modifying antiparkinsonian drug therapy.
History Notes
27/10/2022
East Region Formulary content agreed.
Drugs used in parkinsonism are particularly prone to give side-effects in older patients. Treatment should be initiated with low doses which should be increased with caution.
Dose expressed as levodopa: initially 50mg (e.g. 12.5mg/50mg) levodopa up to 3 times daily. Increase at weekly intervals if necessary according to response. Max 800mg levodopa daily in 3-4 divided doses. Higher doses may be necessary under specialist advice. Prescribers should take care with what formulation they prescribe.
Dose expressed as levodopa: initially 50mg (e.g. 12.5mg/50mg) levodopa up to 3 times daily. Increase at weekly intervals if necessary according to response. Max 800mg levodopa daily in 3-4 divided doses. Higher doses may be necessary under specialist advice. Prescribers should take care with what formulation they prescribe.
Dose expressed as levodopa: initially 50mg (e.g. 12.5mg/50mg) levodopa up to 3 times daily. Increase at weekly intervals if necessary according to response. Max 800mg levodopa daily in 3-4 divided doses. Higher doses may be necessary under specialist advice. Prescribers should take care with what formulation they prescribe.
Dose expressed as levodopa: initially 50mg (e.g. 12.5mg/50mg) levodopa up to 3 times daily. Increase at weekly intervals if necessary according to response. Max 800mg levodopa daily in 3-4 divided doses. Higher doses may be necessary under specialist advice.
Dose expressed as levodopa: initially 50mg (e.g. 12.5mg/50mg) levodopa up to 3 times daily. Increase at weekly intervals if necessary according to response. Max 800mg levodopa daily in 3-4 divided doses. Higher doses may be necessary under specialist advice.
Dose expressed as levodopa: initially 50mg (e.g. 12.5mg/50mg) levodopa up to 3 times daily. Increase at weekly intervals if necessary according to response. Max 800mg levodopa daily in 3-4 divided doses. Higher doses may be necessary under specialist advice.
Drugs used in parkinsonism are particularly prone to give side-effects in older patients. Treatment should be initiated with low doses which should be increased with caution. Transdermal patches can be used to reduce tablet burden, patient choice should be considered when selecting formulation.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Initially 2mg once daily for 1 week, increased in steps of 2mg at intervals of at least 1 week according to response, to 8mg once daily; increased further in steps of 2-4mg at intervals of at least 2 weeks if required; max 24mg.
Stable patients transferring from ropinirole immediate release tablets, initially once daily dose substituted for total daily dose of equivalent immediate-release tablet.
Initially 2mg once daily for 1 week, increased in steps of 2mg at intervals of at least 1 week according to response, to 8mg once daily; increased further in steps of 2-4mg at intervals of at least 2 weeks if required; max 24mg.
Stable patients transferring from ropinirole immediate release tablets, initially once daily dose substituted for total daily dose of equivalent immediate-release tablet.
Initially 2mg once daily for 1 week, increased in steps of 2mg at intervals of at least 1 week according to response, to 8mg once daily; increased further in steps of 2-4mg at intervals of at least 2 weeks if required; max 24mg.
Stable patients transferring from ropinirole immediate release tablets, initially once daily dose substituted for total daily dose of equivalent immediate-release tablet.
Initially 2mg once daily for 1 week, increased in steps of 2mg at intervals of at least 1 week according to response, to 8mg once daily; increased further in steps of 2-4mg at intervals of at least 2 weeks if required; max 24mg.
Stable patients transferring from ropinirole immediate release tablets, initially once daily dose substituted for total daily dose of equivalent immediate-release tablet.
Initially 2mg once daily for 1 week, increased in steps of 2mg at intervals of at least 1 week according to response, to 8mg once daily; increased further in steps of 2-4mg at intervals of at least 2 weeks if required; max 24mg.
Stable patients transferring from ropinirole immediate release tablets, initially once daily dose substituted for total daily dose of equivalent immediate-release tablet.
Pramipexole should be prescribed by both base and salt, please see dosing instructions for details.
Doses shown as base content with salt content in brackets.
Initial dose 88micrograms (125micrograms) 3 times daily, dose doubled every 5-7 days if tolerated, to 350micrograms (500micrograms) 3 times daily; further increased if necessary by 180micrograms (250micrograms) 3 times daily at weekly intervals; max 3.3mg (4.5mg) daily in 3 divided doses.
Doses shown as base content with salt content in brackets.
Initial dose 88micrograms (125micrograms) 3 times daily, dose doubled every 5-7 days if tolerated, to 350micrograms (500micrograms) 3 times daily; further increased if necessary by 180micrograms (250micrograms) 3 times daily at weekly intervals; max 3.3mg (4.5mg) daily in 3 divided doses.
Doses shown as base content with salt content in brackets.
Initial dose 88micrograms (125micrograms) 3 times daily, dose doubled every 5-7 days if tolerated, to 350micrograms (500micrograms) 3 times daily; further increased if necessary by 180micrograms (250micrograms) 3 times daily at weekly intervals; max 3.3mg (4.5mg) daily in 3 divided doses.
Doses shown as base content with salt content in brackets.
Initial dose 88micrograms (125micrograms) 3 times daily, dose doubled every 5-7 days if tolerated, to 350micrograms (500micrograms) 3 times daily; further increased if necessary by 180micrograms (250micrograms) 3 times daily at weekly intervals; max 3.3mg (4.5mg) daily in 3 divided doses.
Doses shown as base content with salt content in brackets.
Initial dose 260micrograms (375micrograms) once daily, dose to be doubled every 5-7 if tolerated, to 1.05mg (1.5mg) once daily; further increased in steps of 520micrograms (750micrograms) every week if required; max 3.15mg (4.5mg) per day.
Doses shown as base content with salt content in brackets.
Initial dose 260micrograms (375micrograms) once daily, dose to be doubled every 5-7 if tolerated, to 1.05mg (1.5mg) once daily; further increased in steps of 520micrograms (750micrograms) every week if required; max 3.15mg (4.5mg) per day.
Doses shown as base content with salt content in brackets.
Initial dose 260micrograms (375micrograms) once daily, dose to be doubled every 5-7 if tolerated, to 1.05mg (1.5mg) once daily; further increased in steps of 520micrograms (750micrograms) every week if required; max 3.15mg (4.5mg) per day.
Doses shown as base content with salt content in brackets.
Initial dose 260micrograms (375micrograms) once daily, dose to be doubled every 5-7 if tolerated, to 1.05mg (1.5mg) once daily; further increased in steps of 520micrograms (750micrograms) every week if required; max 3.15mg (4.5mg) per day.
Doses shown as base content with salt content in brackets.
Initial dose 260micrograms (375micrograms) once daily, dose to be doubled every 5-7 if tolerated, to 1.05mg (1.5mg) once daily; further increased in steps of 520micrograms (750micrograms) every week if required; max 3.15mg (4.5mg) per day.
Doses shown as base content with salt content in brackets.
Initial dose 260micrograms (375micrograms) once daily, dose to be doubled every 5-7 if tolerated, to 1.05mg (1.5mg) once daily; further increased in steps of 520micrograms (750micrograms) every week if required; max 3.15mg (4.5mg) per day.
Doses shown as base content with salt content in brackets.
Initial dose 260micrograms (375micrograms) once daily, dose to be doubled every 5-7 if tolerated, to 1.05mg (1.5mg) once daily; further increased in steps of 520micrograms (750micrograms) every week if required; max 3.15mg (4.5mg) per day.
Patch applied to skin:
When used for monotherapy: Initially 2mg/24hours, then increased in steps of 2mg/24 hours every week if required; maximum 8mg/24hours per day.
When used as adjunctive therapy: Initially 4mg/24 hours, then increased in steps of 2mg/24 hours every week if required; maximum 16mg/24 hours per day.
Patch applied to skin:
When used for monotherapy: Initially 2mg/24hours, then increased in steps of 2mg/24 hours every week if required; maximum 8mg/24hours per day.
When used as adjunctive therapy: Initially 4mg/24 hours, then increased in steps of 2mg/24 hours every week if required; maximum 16mg/24 hours per day.
Patch applied to skin:
When used for monotherapy: Initially 2mg/24hours, then increased in steps of 2mg/24 hours every week if required; maximum 8mg/24hours per day.
When used as adjunctive therapy: Initially 4mg/24 hours, then increased in steps of 2mg/24 hours every week if required; maximum 16mg/24 hours per day.
Patch applied to skin:
When used for monotherapy: Initially 2mg/24hours, then increased in steps of 2mg/24 hours every week if required; maximum 8mg/24hours per day.
When used as adjunctive therapy: Initially 4mg/24 hours, then increased in steps of 2mg/24 hours every week if required; maximum 16mg/24 hours per day.
Patch applied to skin:
When used for monotherapy: Initially 2mg/24hours, then increased in steps of 2mg/24 hours every week if required; maximum 8mg/24hours per day.
When used as adjunctive therapy: Initially 4mg/24 hours, then increased in steps of 2mg/24 hours every week if required; maximum 16mg/24 hours per day.
Patch applied to skin:
When used for monotherapy: Initially 2mg/24hours, then increased in steps of 2mg/24 hours every week if required; maximum 8mg/24hours per day.
When used as adjunctive therapy: Initially 4mg/24 hours, then increased in steps of 2mg/24 hours every week if required; maximum 16mg/24 hours per day.
Use of dispersible tablets is restricted to patients with swallowing difficulties or where rapid absorption is required, doses are equivalent. Use of modified-release preparations should be used for nocturnal motor dysfunction.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Prescribing Notes:
- Dopamine agonists, and less commonly levodopa, may cause impulse control disorders (pathological gambling/shopping, hypersexuality). Patients and carers should be advised in advance of these potential adverse effects. If the patient develops an impulse control disorder, contact specialist teams to discuss advice for titrating downwards slowly, until the symptoms resolve or are manageable in the context of their overall motor control.
- To reduce the risk of nausea, levodopa should be taken initially with food for two weeks and the dose increased slowly. If tolerated levodopa is better absorbed on an empty stomach at least half an hour before or after food, as protein may interfere with levodopa absorption. Levodopa should not be withdrawn abruptly. It may colour urine red.
- Co-beneldopa and co-careldopa are used equally and there is no evidence of benefit of one over the other.
- When used as adjunctive therapy, COMT and MAO-B inhibitors can contribute to levodopa-induced adverse effects.
- All dopamine agonists, and less commonly levodopa, can cause postural hypotension and neuropsychiatric adverse effects. Sudden onset of sleep can occur with dopamine-receptor agonists.
- Rotigitine has an additional role for inpatients who are nil by mouth, please see local guidelines for conversion doses.
History Notes
27/10/2022
East Region Formulary content agreed.
Using immediate release medicine - initially 5mg once daily for 2-4 weeks, then increased if tolerated to 10mg daily, dose to be taken in the morning.
Using immediate release medicine - initially 5mg once daily for 2-4 weeks, then increased if tolerated to 10mg daily, dose to be taken in the morning.
1mg daily.
Prescribing Notes:
- Selegiline (oral or buccal) may be used for management of motor fluctuations.
- A buccal formulation of selegiline produces less side effects but is considerably more expensive than the oral formulation. It should only be considered in patients with swallowing problems or intolerance of standard selegiline.
History Notes
27/10/2022
East Region Formulary content agreed.
Drugs used in parkinsonism are particularly prone to give side-effects in older patients. Treatment should be initiated with low doses which should be increased with caution.
Dose as per specialist.
If patients tolerate entacapone individual tablets alongside their levodopa/carbidopa then they can be switched to a combination pill for convenience/ reduce pill burden. Patients may be initiated on a combined therapy when addition of entacapone is required.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Opicapone is used in combination with levodopa / DOPA decarboxylase inhibitors when patients have end-of-dose motor fluctuations who cannot be stabilised on those combinations.
50mg once daily, taken at bedtime, at least one hour before or after levodopa combinations.
Prescribing Notes:
- Entacapone (oral) may be used for management of motor fluctuations.
- Entacapone can turn secretions orange.
- Opicapone can cause levodopa dose to have to be reduced due to dyskinesias.
History Notes
27/10/2022
East Region Formulary content agreed.
100mg daily for 1 week, then increase to 100mg twice daily if tolerated, usually administered in conjunction with other treatment. Maximum 400mg daily.
100mg daily for 1 week, then increase to 100mg twice daily if tolerated, usually administered in conjunction with other treatment. Maximum 400mg daily.
Prescribing Notes:
- Amantadine may be useful for control of dyskinesia.
Amantadine improves mild bradykinetic disabilities, tremor and rigidity. It may also be useful in dyskinesias in more advanced disease. Doses of amantadine should be given earlier in the day as it can interfere with sleep. If lower doses are required to initiate or titrate amantadine the solution can be used to give 50mg increments.
History Notes
27/10/2022
East Region Formulary content agreed.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Dose as per specialist.
Prescribing Notes:
- Apomorphine is a powerful dopamine agonist that must be given subcutaneously, either by infusion or on an “as required” basis. It is appropriate for a shared care arrangement to facilitate the seamless transfer of individual patient care from secondary care to general practice. For advice on minimising risk of cardiac side effects see MHRA Drug Safety Update, April 2016.
- Co-careldopa intestinal gel (Duodopa) is approved for the treatment of advanced levodopa-responsive Parkinson’s disease with severe motor fluctuations and hyper/dyskinesia when available combinations of Parkinson medicinal products have not given satisfactory results. Restricted to use in patients not eligible for deep brain stimulation (DBS).
- Foslevodopa-foscarbidopa (Produodopa) is approved for the treatment of advanced levodopa-responsive Parkinson's disease with severe motor fluctuations and hyperkinesia or dyskinesia when available combinations of Parkinson medicinal products have not given satisfactory results. Restricted to use in patients not eligible for deep brain stimulation (DBS).
History Notes
27/02/2025
Addition of APO-go POD and Foslevodopa + Foscarbidopa (SMC2574), ERFC Feb 25.
12/06/2024
Dacepton added, ERFC Dec 23.
27/10/2022
East Region Formulary content agreed.