By Lorri A. Lee, MD, and Tricia A. Meyer, PharmD, MS, FASHP
An estimated one million people in the United States have been diagnosed with Parkinson’s Disease (PD) making it one of the most common neurological disorders in patients. This number is estimated to double in the next 30 years as PD is associated with increasing age. PD patients have a deficiency of dopamine in their brain and many of their medications are used to increase this neurotransmitter. They are frequently very sensitive to missing even one dose of their Parkinson medications and may exhibit increased rigidity, loss of balance, agitation, and confusion if their dosing schedule is delayed. Neuroleptic malignant syndrome or parkinsonism-hyperpyrexia syndrome can develop if their medications are held too long or as a result of serious infection.1 Many drugs used in the perioperative period, such as metoclopramide, butyrophenones (haloperidol, droperidol), and phenothiazines (promethazine, prochlorperazine) have anti-dopaminergic activity that can worsen the symptoms of PD.
Depression is a common neuropsychiatric manifestation of PD and many of these patients will be taking serotonergic antidepressants that can interact with serotonergic medications administered in the perioperative period and cause the potentially fatal serotonin syndrome. The potent monamine oxidase inhibitor (MAOI) methylene blue is a frequent precipitator of serotonin toxicity in the hospital in patients who are taking other serotonergic medications. Methylene blue predominantly inhibits MAO-A which is responsible for deaminating serotonin.
PD patients may be prescribed selective MAOI-B medications such as selegiline and rasagiline that inhibit metabolism of dopamine. Though caution is still advised, several studies have demonstrated that the risk of serotonin syndrome with these selective MAOI-B drugs is extremely low, even in combination with serotonergic antidepressants.
Acetylcholinesterase inhibitors for PD dementia (rivastigmine, donepezil, and galantamine) are commonly prescribed, and these drugs have been associated with a prolonged effect of succinylcholine (up to 50 minutes) and increased resistance to non-depolarizing neuromuscular blocking drugs.
Treatment for PD is polypharmacy with the potential for numerous adverse drug interactions with perioperative medications. Anesthesia professionals should be aware of the symptoms and signs of PD exacerbations, neuroleptic malignant syndrome (parkinsonism-hyperpyrexia syndrome), and serotonin toxicity2 and understand which commonly used anesthetic drugs possess anti-dopaminergic and serotonergic activity.3 In addition, PD patients have difficulty swallowing and are at increased risk for aspiration and falls. They have increased lengths of stay and increased complications with surgery.1
Because of these concerns, the Institute for Safe Medication Practices (ISMP) issued a recent medication safety alert with recommendations on the medication management and perioperative care of PD patients (https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=103).4 Placing these patients as first start cases and making sure they stay on their scheduled PD medications during their NPO status is recommended when possible. For elective cases, some medications such as acetylcholinesterase inhibitors may be stopped 1–2 weeks prior to surgery but should preferably only be discontinued in consultation with the patient’s neurologist. Development of departmental guidelines for perioperative management of PD patients may be useful to detail the myriad potential drug interactions and perioperative care issues.
The authors have no conflicts of interest to declare for this article.
Dr. Lee is Co-Editor of the APSF Newsletter and Professor of Anesthesiology and Neurological Surgery at Vanderbilt University Medical Center in Nashville, TN.
Dr. Meyer is Regional Director and Associate Professor of Anesthesiology at Baylor Scott & White Health, Texas A&M College of Medicine in Temple, TX.
- Katus L, Shtilbans A. Perioperative management of patients with Parkinson’s disease.Am J Med 2014; 127:275-80.
- Ables AZ, Nagubilli R. Prevention, recognition, and management of serotonin syndrome.Am Fam Physician 2010;81:1139-42.
- Baruah J, Easby J, Kessell G. Effects of acetylcholinesterase inhibitor therapy for Alzheimer’s disease on neuromuscular block.Br J Anaesth 2008;100:420.
- Institute for Safe Medication Practices. Delayed administration and contraindicated drugs place hospitalized Parkinson’s disease patients at risk. March 12, 2015.https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=103. Accessed August 13,201