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 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 |
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 |
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