Non-Ergot Dopamine Receptor Agonists


Pramipexole, Ropinirole, Rotigotine

 [For apomorphine – see separate monograph]


  Issues for Surgery


For Parkinson’s Disease (PD) - risk of exacerbation of PD and akinesia if omitted1.

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

Continue2.

EXCEPT: 

Neupro® (rotigotine) patch should be removed prior to magnetic resonance imaging or cardioversion to avoid skin burns as the backing layer of the patch contains aluminium3, 4; for PD patients seek advice from patient’s specialist.

For patients who may decide to quit smoking during the perioperative period see Further Information.

For PD patients receiving oral preparations 
To minimise disruption to the patient’s usual medication regime oral dopamine receptor agonists can be given with a sip of water up until anaesthetic induction2.

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 / medications5.

Post-operative Advice

Resume post-operatively at patient’s usual dose.

If doses of ropinirole are missed dose re-titration is necessary (see Further Information).

For PD patients receiving oral preparations
If a long NBM period is anticipated or if there are concerns regarding enteral absorption alternative routes/medications should be considered2, 5 (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’.

Hypotension

Non-ergot dopamine receptor agonists can increase the risk of hypotension when used concomitantly with inhalational or intravenous anaesthetics4.


  Interaction(s) with other Common Medicines used in the Perioperative Period


Antiemetics

Non-ergot dopamine receptor agonists can increase the risk of hypotension when used concomitantly with droperidol or prochlorperazine4. However, these medications should be avoided in patients with PD as they exacerbate symptoms4.

For general information regarding the use of antiemetics in PD – see Parkinson’s Disease – A General Overview’.

Ciprofloxacin

Ciprofloxacin inhibits CYP1A2; this is the main route of metabolism of ropinirole and therefore it is predicted to increase the exposure to ropinirole. Manufacturer advises adjust ropinirole dose4, 6, 7.


  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 temporarily2, 3, 4, 6, 8.

Smoking Cessation

Quitting smoking pre-operatively improves surgical outcomes through reducing risk of post-operative complications9. Smoking induces CYP1A2, by which ropinirole is extensively metabolised. If a patient decides to quit smoking during the perioperative period it must be remembered that smoking cessation can reduce ropinirole clearance – dosage adjustments might be necessary4, 6, 7.

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 DAWS. 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 opportunity5.

If PD treatment is interrupted for more than one day or restless legs treatment is interrupted for more than a few days the manufacturer of ropinirole advises doses should be re-titrated4, 6.

Prescribing and Administration

Access to the correct medication / formulation at the correct time remains a problem for people with PD whilst they are in hospital5. 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


  1. 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]
  2. Chambers DJ. Sebastian J. and Ahearn DJ. Parkinson’s disease. BJA Education. 2017; 17:145-149
  3. 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]
  4. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 10th August 2019]
  5. Brennan KA & Genever RW. Managing Parkinson’s disease during surgery. BMJ. 2010; 341:c5718
  6. Summary of Product Characteristics – Requip XL® (ropinirole) prolonged-release tablets. GlaxoSmithKline UK. Accessed via www.medicines.org.uk 10/08/2019 [date of revision of the text November 2017]
  7. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 10th August 2019]
  8. Summary of Product Characteristics – Mirapexin® (pramipexole) 0.088mg tablets. Boehringer Ingelheim Limited. Accessed via www.medicines.org.uk 10/08/2019 [date of revision of the text February 2018]
  9. 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]