Parkinson’s disease medicines in swallowing difficulties

Using our advice

Please see Medicines suitable for adults with swallowing difficulties (SPS page)

The choice of medicine formulation should be made on an individual basis, taking account of patient factors. Follow our stepwise guide Choosing medicines formulations in swallowing difficulties (SPS page)

There are additional considerations in Parkinson’s disease. This article covers these and suggests how Parkinson’s medicines may be given safely in swallowing difficulties, to avoid missed or delayed doses.

Swallowing difficulties in Parkinson’s

People with Parkinson’s disease are at increased risk of swallowing difficulties. A change in swallow status should prompt a review, including medication review, by the specialist team.

Swallow status should be included in hospital admission checklists and documented in discharge summaries; check patient records for details.

Parkinson’s disease medicines are ‘time critical medicines’. Patients are at risk of harm if doses are delayed or missed. See our series Understanding time critical medicines to support improvement (SPS page) for further guidance and support.

Avoid missing or delaying doses

Parkinson’s disease medicines must be given on time. Delayed or missed doses can lead to serious problems, including acute akinesia and potentially fatal neuroleptic malignant syndrome (NMS). Even a 30-minute delay can worsen symptoms such as tremor, rigidity and loss of balance. Swallowing difficulties are exacerbated by medicines not being given on time.

Dose administration schedules are tailored to the individual patient to manage their symptoms. Parkinson’s UK’s ‘Get it on time’ campaign highlights the importance of timely administration of Parkinson’s disease medicines for people in hospitals or care homes.

Consider crushing tablets or opening capsules to enable medicines administration in a timely manner. Not all tablets and capsules are suitable for administration this way. Use the information in this article to check individual medicines.

Monitor the patient

When changes are made to the administration of Parkinson’s medicines, monitor the patient closely for changes in tremor, stiffness, discomfort and cognitive state.

Seek specialist advice

Swallowing difficulty may indicate disease progression and the patient’s medication needs may have changed. Patients with a change in swallow status require specialist review at the earliest opportunity.

If possible, liaise with the patient’s Parkinson’s disease specialist team when advising on medicines administration, without delaying doses. Changes to complex medication regimens require specialist input.

Crushing tablets or opening capsules may allow administration of a patient’s current medication while awaiting specialist input, to avoid a delayed or missed dose. Not all tablets and capsules are suitable for administration this way. Use the information in this article to check individual medicines.

In many cases, crushing tablets or opening capsules is ‘off-label’. For carers or care home staff to administer medicines in an ‘off-label’ way, the prescriber must make a written direction. Instructions must be included in the patient’s Medication Administration Record (MAR) chart and care plan.

Give Madopar consistently regarding food

The manufacturer advises that Madopar (co-beneldopa) immediate-release preparations should be given on an empty stomach, as levodopa absorption can be reduced if taken with a protein-rich meal.

There are no similar recommendations for other Parkinson’s medicines, including for generic co-beneldopa preparations.

In practice, any impact on absorption is generally consistent as long as the medicine is taken the same way each time – whether with a snack, a meal or on an empty stomach. Do not delay doses to fit around food intake.

If switching from taking levodopa-containing medicines on an empty stomach to taking them with food, monitor the patient’s response and adjust the dose if necessary.

Always ensure the full dose of medication is taken. If mixing with food, use a small amount. Why and how medicines are given with soft food or thickened fluid (SPS page) provides practical advice, including the choice of food.

Oral Parkinson’s medicines suitable in swallowing difficulties

Medicines are listed alphabetically by generic name. Licensed status is noted.

Use licensed medicines, including ‘off-label’, in preference to unlicensed medicines. Step 4 of Choosing medicines formulations in swallowing difficulties (SPS page) explains further.

Due to potential changes in bioavailability, patients should be monitored and doses adjusted according to response when tablets are crushed or capsules opened.

Amantadine capsules

Can be opened and the contents mixed with water or soft food. This is ‘off-label’.

Amantadine 50mg/5ml oral solution

Available as a licensed preparation. It does not require fridge storage and has an expiry of 28 days after opening.

Amantadine 50mg/5ml syrup

Available as a licensed preparation. It does not require fridge storage.

Bromocriptine tablets

Can be crushed and dispersed in water or given with soft food. This is ‘off-label’.

Cabergoline tablets

Can be crushed and mixed with water or soft food. This is ‘off-label’.

Co-beneldopa capsules

Co-beneldopa (Madopar or generic) immediate-release capsules can be opened and the contents mixed with water or soft food. This is ‘off-label’. The capsule contents are reported to taste bitter. Give Madopar capsules consistently with regard food.

Modified-release co-beneldopa

Do not open  modified-release (Madopar CR) capsules. Patients can be switched to immediate-release capsules or dispersible tablets. When switching from modified-release capsules to immediate-release capsules or dispersible tablets, consider reducing the total daily levodopa dose by 25 to 30% and round to the nearest number of whole immediate-release capsules or dispersible tablets. Give in divided doses.

Co-beneldopa dispersible tablets

Co-beneldopa (Madopar) dispersible tablets are licensed for administration with water or orange squash (not orange juice). The manufacturer recommends tablets are dispersed in at least 25ml water or diluted orange squash per tablet.

The dispersible tablets can be crushed and given with soft food. This is ‘off-label’. Give Madopar dispersible tablets consistently with regard food.

Switching to co-beneldopa dispersible tablets

If switching from immediate-release co-careldopa or co-beneldopa preparations, continue the same total daily levodopa dose, in divided doses.

If switching from modified-release co-careldopa or co-beneldopa preparations, consider reducing the total daily levodopa dose by 25 to 30% and round to the nearest number of whole tablets. Give in divided doses.

If switching from some other Parkinson’s medicines, an online calculator can be used, alongside clinical reasoning, to determine the levodopa-equivalent dose of the patient’s medicines. This enables patients to be switched to an appropriate dose of Madopar dispersible tablets. The calculator assumes patients are in hospital and that medicines will be given via feeding tube. Seek advice from the Parkinson’s specialist team when using the calculator, if possible.

In all cases of switching, monitor the patient and adjust the dose if necessary, according to response.

Co-careldopa tablets

Co-careldopa (Sinemet, Sinemet Plus or generic) immediate-release tablets can be dispersed in water or mixed with soft food. This is ‘off-label’.

Co-careldopa modified-release

Do not crush co-careldopa modified-release tablets. Brands include Sinemet CR, Half Sinemet CR, Caramet CR and Lecado CR. Patients can be switched to immediate-release co-careldopa tablets, or to co-beneldopa (Madopar) dispersible tablets. When switching from prolonged-release tablets to immediate-release tablets or Madopar dispersible tablets, consider reducing the total daily levodopa dose by 25 to 30% and round to the nearest number of whole tablets. Give in divided doses.

Entacapone tablets

Can be crushed and mixed with water, orange juice or soft food. This is ‘off-label’. The tablets are film-coated and may taste bitter once crushed.

Entacapone + co-careldopa tablets

Stalevo, Sastravi and Stanek tablets can be crushed and mixed with water, orange juice or soft food. This is ‘off-label’.

Opicapone capsules

Can be opened and the contents mixed with water or soft food. This is ‘off-label’. The capsule contents are heavily yellow coloured and may turn the patient’s mouth yellow.

Pramipexole tablets

Immediate-release tablets can be crushed and mixed with water. This is ‘off-label’.

Pramipexole modified-release

Do not crush pramipexole modified-release tablets. Patients can be switched to the same total daily dose of immediate-release pramipexole, given in three divided doses. If necessary, round to the nearest strength immediate-release preparation.

Rasagiline tablets

Can be crushed and mixed with water or soft food. This is ‘off-label’.

Ropinirole tablets

Immediate-release tablets can be crushed and/or dispersed in water or crushed and given with soft food. This is ‘off-label’. They are film-coated so may taste bitter once crushed.

Ropinirole modified-release

Do not crush ropinirole modified-release tablets. Patients can be switched to the same total daily dose of immediate-release ropinirole, given in three divided doses. If necessary, round to the nearest strength immediate-release preparation.

Safinamide tablets

Can be crushed and mixed with water or soft food. This is ‘off-label’. The tablets are film-coated so may taste bitter once crushed.

Selegiline tablets

Can be dispersed in water or crushed and mixed with soft food. This is ‘off-label’.

Tolcapone tablets

Can be crushed and mixed with water or soft food. This is ‘off-label’. They are film-coated so may taste bitter once crushed.

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