When the PD Patient Needs Surgery by Michael Rezak, M.D., Ph.D. Vassar Hospital and Medical Center
Recently, I have received a number of inquiries regarding PD patients who have scheduled surgical procedures and some who have required emergency surgery. Special consideration must be given to the PD patient that requires any surgical intervention. The physical and emotional stress that surgical procedures can impose impacts PD management. Foreknowledge of potential problems may preclude their development.
In the paragraphs that follow, I have decided to follow a question and answer format using actual questions posed by patients and their families as well as by physicians. The selected questions will also address potential complications seen in PD patients that undergo any surgical procedure.
Q) When should PD medications be discontinued before surgery and how soon can they be restarted following surgery?
A) PD medications should be continued as close to the surgical procedure as possible. This is typically about 3 hours before the procedure, thereby allowing the patient to remain as comfortable as possible.
There is no longer a need to discontinue MAO-B inhibitors (particularly Azilect®) before surgery as this class of medicine has been shown to be safe with anesthetics and most pain medicines. The only contraindicated pain medicines with AzilectÆ are meperidine and tramadol. To date, there have been no negative interactions documented with MAO-B inhibitors and pain medicines.
Following surgery PD medications should be restarted as soon as the patient can safely swallow. Unfortunately, if problems with swallowing continue or the patient is not allowed to take oral medications, there are only a limited number of effective dopaminergic drugs that can be administered by routes other than through the mouth. These medications are Apokyn® (apomorphine), Cogentin® (benztropine), NeuproÆ (rotigotine), Zelapar® (selegeline) and InbrijaÆ. (inhaled levodopa).
In most cases, if a patient recovering from gastrointestinal surgery requires l-dopa, I recommend giving this medication via nasogastric tube with suction off and the tube clamped for 30-45 minutes after the medicine is delivered, to fully allow absorption.
Apokyn® is an injectable dopamine receptor agonist and is ordinarily considered a “rescue drug” for those experiencing sudden “off episodes.” and is probably the most efficacious and rapidly acting of the drugs that can be given by routes other than oral. However, in the post-operative setting this medicine can become the mainstay of treatment and/or used along with other medicines. This medication must be used with caution in the post-operative period (especially if an effective dose has not been established pre-operatively) and only if an anti-emetic is used concurrently because it can and often does cause nausea and vomiting.
Zelapar® is a MAO-B inhibitor that is uniquely absorbed through the oral mucosa thereby bypassing the gastrointestinal tract. It can be used along with l-dopa or any of the other drugs mentioned here.
NeuproÆ is a dopamine receptor agonist that is delivered transdermally bypassing the gastrointestinal tract, providing continuous delivery. It can be used alone or with the other medications depending on the patient.
InbrijaÆ is a formulation of levodopa that can be inhaled, entering the blood stream through the lungs. Unfortunately, doses are limited, but still may be helpful under the right circumstances along with other medicines for some patients.
Q) What are the dangers in delaying restarting dopaminergic medications after surgery?
A) The post-operative period can be difficult under any circumstances, however with the additional burden that PD imposes, resumption of optimal motor function as soon as possible is of paramount importance in order to minimize potential post-operative problems.
First, delay in reinitiating PD medications can compromise motor function including those of respiratory (breathing) and pharyngeal (swallowing) muscles. Poor respiratory muscle function can lead to impaired coughing and restricted movement of the respiratory muscles (limiting deep breaths). Additionally, swallowing problems can develop or worsen without PD meds, thus increasing the risk of aspiration. These problems, taken together with the decreased ability to move about, make the common post-operative complication of pneumonia much more likely.
Second, the rigidity, bradykinesia and resultant decrease in movement brought about by the lack of PD medications increase the post-operative risk of developing blood clots in the legs (deep venous thrombosis or DVT) related to sluggish blood flow. In some cases, these blood clots can travel to the lungs causing a life-threatening pulmonary embolus. Mobilization is therefore a major post-operative goal after any surgery and not being on appropriate PD medications increases risks and delays optimal rehabilitation.
Finally, a rare, but potentially life-threatening condition known as neuroleptic malignant syndrome (NMS) must be a concern whenever dopaminergic drugs are stopped abruptly. In NMS, mental status changes, rigidity, tremor, fever and autonomic instability can have serious consequences. If recognized early, treatment can be life-saving.
Q) Should a PD patient do anything special pre-operatively to maximize the possibility of a good recovery?
A) Of course, obtaining general medical clearance prior to surgery is the standard of care. This allows for correction of any existing problems before the surgical procedure. Additionally, I recommend that some patients undergo a formal video-fluoroscopic swallowing evaluation as well as obtain pulmonary function tests so that baseline measurements can be documented and appropriate planning for potential post-operative complications be instituted. Also, it is important to stop any prescription or over-the-counter medications that increase bleeding such as Coumadin®, Plavix®, EliquisÆ, XareltoÆ, PradaxaÆ, aspirin, ibuprofen, vitamin E, Gingko Biloba, etc. Maintaining good hydration and appropriate nutritional status as well as optimizing overall physical conditioning will maximize the potential for a good and smooth recovery.
Q) What medications should be avoided following surgery?
A) Needless to say, all drugs that block dopaminergic transmission need to be avoided. Post-operative nausea and vomiting is extremely common and medications such as Reglan®, Compazine®, and Phenergan® are considered first line medications to treat this problem. Because of their interference with dopamine transmission they will certainly worsen PD symptoms and should therefore be avoided. If treatment for nausea and vomiting is needed for the PD patient, the drug of choice is Zofran® or alternatively Tigan®. These drugs do not interfere with dopamine function and can be given intravenously or orally.
Post-operative confusion and agitation is another situation where dopamine-blocking agents are often employed. The older neuroleptics such as Haldol® and closely related drugs should be avoided. The newer, so called, “atypical neuroleptics” such as Abilify®, Risperdal® and Zyprexa® may also have a deleterious effect on motor function in PD patents. The drugs of choice for the treatment of post-operative delirium are Seroquel®, NuplazidÆ and Clozaril®. They are effective and have only minor impact on PD symptoms. Seroquel® is easy to use, is readily available, and has a relatively rapid onset of action. SeroquelÆ is considered the best option for the PD patient and it has the least impact on dopamine receptors.
In general, when the PD patient needs hospitalization multiple copies of the medication schedule with exact times of administration should be supplied to all of the physicians and nurses involved in their care. Upon arrival to the hospital a discussion of PD and the importance of proper medication administration should take place with the staff. If possible, an advocate (e.g. spouse, child, caregiver) should be assigned with the task of assuring that medications are given on time and in the correct doses. If possible, a pre-operative meeting with the anesthesiologist and surgeon emphasizing the critical nature of the medication schedule should be performed.
In closing, I hope that through these questions and answers I have emphasized that “micro-managing” the PD patient, before, during and after a surgical procedure decreases the risk of complications and increases the likelihood of a good and full recovery. As always, it is important for the PD patient to be his or her advocate in assuring that all of the details are in order.
