Co-beneldopa: Levodopa with Benserazide, Co-careldopa: Levodopa with Carbidopa
Issues for Surgery
Risk of exacerbation of Parkinson’s Disease (PD) and akinesia if omitted1.
Risk of Parkinsonism-Hyperpyrexia Syndrome (PHS) if omitted (see Further Information).
Risk of hypotension if continued (see Interaction(s) with Common Anaesthetic Agents).
Advice in the Perioperative period
Elective and Emergency Surgery
Continue (including combination products) 2, 3, 4, 5, 6.
Combination Products: -
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 induction2. Duodopa® intestinal gel can be continued for as long as the patient is permitted to take fluids by mouth5.
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)7 – for advice on equivalent doses see http://parkinsonscalculator.com/ 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 / medications7.
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 allowed3, 4, 5.
If a long NBM period is anticipated or if there are concerns regarding enteral absorption, alternative routes / medications should be considered2, 7 (see Further Information).
Interaction(s) with Common Anaesthetic Agents
For general information regarding the use of anaesthetic agents in PD – see ‘Parkinson’s Disease – A General Overview’.
Levodopa preparations can increase the risk of hypotension when used concomitantly with inhalational or intravenous anaesthetics8.
The manufacturers advise caution with concomitant administration of co-beneldopa and sympathomimetics e.g. epinephrine / adrenaline, norepinephrine / noradrenaline as their action may be potentiated4. Dose reduction and monitoring of cardiovascular adverse effects is advised4. No recommendation is made regarding other sympathomimetics e.g. ephedrine, metaraminol, phenylephrine.
Interaction(s) with other Common Medicines used in the Perioperative Period
Cyclizine may decrease the absorption of levodopa8; however, this is unlikely to be clinically significant, as cyclizine is generally considered useful in patients with PD2, 9.
Levodopa preparations can increase the risk of hypotension when used concomitantly with droperidol or prochlorperazine8. However, these medications should be avoided in patients with PD as they exacerbate symptoms8.
For general information regarding the use of antiemetics in PD – see ‘Parkinson’s Disease – A General Overview’.
Iron forms chelation complexes with levodopa and carbidopa leading to a reduced bioavailability and possible worsening of symptoms3, 4, 9; this appears to be clinically significant in some patients4, 9. Iron and levodopa administration should be separated as much as possible and the patient monitored for deterioration in symptoms10.
Parkinsonism – Hyperpyrexia Syndrome (PHS)
Abrupt withdrawal of levodopa can result in PHS1, 2, 7, 10. It is most common in individuals with severe Parkinson’s symptoms or on larger doses of levodopa6. Symptoms mimic those of neuroleptic malignant syndrome and include muscle rigidity, fever, cardiovascular instability, profuse sweating and altered mental status (agitation, delirium, and coma)2, 10. PHS carries a significant mortality, up to 20% in untreated cases2.
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 / medications should be considered – see ‘Parkinson’s Disease – A General 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 opportunity7.
Prescribing and Administration
Access to the correct medication / formulation at the correct time remains a problem for people with PD whilst they are in hospital7. 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.