Spontaneous wriggling or writhing movements which can occur when the medicine is working (i.e. the patient is 'on').
A rhythmic, oscillating movement, most commonly of the hands and or limbs.
When the patient is adequately treated and movements are reasonably fluent and spontaneous.
When when the patient's medication has worn off and movements are slow, deliberate and difficult. Other less visible symptoms of pain and distress may be a feature for some patients.
A noticeable transition from 'on' to 'off' occurring between doses of medication.
An umbrella term for the motor complications of more 'brittle' advanced disease. Patients can fluctuate from 'off', to 'on' and "on with dyskinesia." The change may be gradual or a sudden switch.
Co-careldopa 12.5/50
Co-careldopa 10/100
Co-careldopa 25/100
Co-careldopa 25/250
Co-careldopa CR 50/200
Co-careldopa CR 25/100
Co-beneldopa 12.5/50
Co-beneldopa 25/100
Co-beneldopa 50/200
Co-beneldopa 25/100
levodopa 50mg / carbidopa 12.5mg / entacapone 200mg
levodopa 75mg / carbidopa 18.75mg / entacapone 200mg
levodopa 100mg / carbidopa 25mg / entacapone 200mg
levodopa 125mg / carbidopa 31.25mg / entacapone 200mg
levodopa 150mg / carbidopa 37.5mg / entacapone 200mg
levodopa 200mg / carbidopa 50mg / entacapone 200mg

For Clinicians

Parkinson's Disease

Treating patients who can't swallow/absorb

Guidelines on the Management of Parkinson's Disease (PD) Patients with Swallowing Difficulties or Who are 'Nil By Mouth' (NBM)

Patients with PD are often on complicated regimes to manage their disease. If they don't receive their usual medication on time symptoms can quickly increase, along with the risk of adverse inpatient events and prolonged length of stay. When PD medications are withdrawn abruptly patients are also at risk of developing Neuroleptic Malignant Syndrome. It is imperative that if a patient with PD is unable to swallow their usual medication that alternatives are sought. Many of the PD medications can be changed to soluble, crushable or dispersible alternatives and given by mouth or via NG.

Do NOT omit medication

Specialist advice is available during normal working hours. Refer all patients with concerns regarding swallow who are unable to take their usual medication. Mark as urgent.

  • Older People's Movement Disorder Service: Fax 1287
  • Neurology: Fax 1865

PD patient with swallowing difficulties
Inform Ward Pharmacist, Speech & Language Therapy
Has the patient been declared 'Nil by Mouth'?
Can NG tube be placed?
Start rotigotine patch


Flow chart

Change levodopa containing preparations (Madopar, Sinemet, Stalevo) to Madopar dispersible via NG tube – see section 1

Withold entacapone – seek advice

Give oral dopamine agonists via NG – see section 2

Selegiline and rasagiline: disperse in water
Change levodopa preparations (Madopar, Sinemet, Stalevo) to Madopar dispersible
see section 1

Give dopamine agonists as
prepared below – see section 2

NB - Thickener can be added to all preparations when dispersed if needed
If patients are admitted on an apomorphine pump or Duodopa infusion, contact Pulteney Ward for Nursing support - see section 3

Section 1 - Converting Levodopa preparations to Madopar Dispersible

Change all levodopa preparations to the equivalent dose of Madopar Dispersible tablets as below and give at usual timings.

Madopar Dispersible:

Madopar dispersible tablets are available from pharmacy during normal working hours or check intranet stock list for nearest ward availability. Pulteney Ward keeps stocks of most PD medications - or via Emergency Ward cupboard or on call Pharmacist.

Madopar (co-beneldopa) and Sinemet (co-careldopa) tablets – convert to Madopar dispersible tablets as below:

Sinemet (co-careldopa) Madopar (co-beneldopa) Madopar Dispersible
Sinemet 62.5mg Madopar 62.5mg Madopar Disp 62.5mg
Sinemet 110   Madopar Disp 125mg
Sinemet Plus Madopar 125mg Madopar Disp 125mg
Sinemet 275mg Madopar 250mg Madopar Disp 125mg x2
Sinemet CR   Madopar Disp 125mg x2 (reduce to 125mg if causes dyskinesia or bad dreams)
Half Sinemet CR Madopar CR Madopar Disp 125mg

Stalevo (Sinemet/entacapone combination) tablets - Change to Madopar Dispersible using this conversion table:

Stalevo preparations Madopar dispersible substitute **
Stalevo 50 Madopar dispersible 62.5mg
Stalevo 75 Madopar dispersible 62.5mg
Stalevo 100 Madopar dispersible 125mg
Stalevo 125 Madopar dispersible 125mg
Stalevo 150 Madopar dispersible 125mg
plus Madopar dispersible 62.5mg
Stalevo 200 Madopar dispersible 125mg x 2

The above is an initial rough guide for changing to Madopar dispersible. Madopar dispersible will give a higher peak dose and a shorter duration of action. The number of doses per day may need to increase to compensate for stopping the entacapone component e.g change from 4 hourly spacing to 3 hourly if Parkinson's symptoms increase before the next dose. If excess dyskinesia reduce the dose and give more often (eg change Madopar dispersible 125mg x 2 given 4 hourly to Madopar 125mg given 3 hourly).

Entacapone (invariably prescribed in addition to Levodopa)

If on Sinemet plus separate entacapone tablets or Madopar plus entacapone prescribe the Sinemet or Madopar doses as Madopar dispersible (dose equivalent as in table). Use the same timings as prior to admission, withhold entacapone and seek advice once in working hours as dose timings may need to be brought closer together.

Section 2 – Dopamine agonist medications (ropinirole and pramipexole and cabergoline)


Ropinirole Prolonged Release tablets. Do NOT crush or give via NG tube. Convert to the equivalent dose of short acting ropinirole Divide daily prolonged release dose by 3 to give nearest equivalent tds dose. Short acting ropinirole Can be crushed and mixed with water for administration via Ng tube or crushed and given with water +/- thickener or soft food Max dose 24mg Space evenly eg 8am, 2pm and 8pm Rotigotine equivalent dose (if NG not possible)
2 – 4mg 1mg tds 2mg
5 - 6mg 2mg tds 4mg
7 – 9mg 3mg tds 6mg
10 – 12mg 4 mg tds 8mg
13 - 15mg 5mg tds 10mg
16 – 18mg 6mg tds 12mg
19 – 21mg 7mg tds 14mg
22 – 24mg 8mg tds 16mg


Pramipexole Prolonged Release once daily. Do NOT crush or give via NG tube. Convert to short acting pramipexole or rotigotine patch (NB Pramipexole can be prescribed as either base or salt – the doses differ) Short acting pramipexole equivalent dose Can be crushed and mixed with water (+/- thickener) or given via NG tube Give three times a day eg 8am, 2pm and 8pm Rotigotine equivalent dose (if NG not possible)
0.26mg (base) 0.375mg (salt) 88mcg tds (base) 2mg
0.52mg (base) 0.75mg (salt) 180mcg tds (base) 4mg
1.05mg (base) 1.5 mg (salt) 350mcg tds (base) 6mg
1.57mg (base) 2.25mg (salt) 350mcg plus 180mcg given together tds (base) 8mg
2.10 mg (base) 3.0 mg (salt) 700mcg tds (base) 10mg
2.62mg (base) 3.75mg (salt) 700mcg plus 180mcg given together tds (base) 12mg
3.15mg (base) 4.5 mg (salt) 700mcg plus 350mcg given together tds (base) 16mg

If taking cabergoline, convert to rotigotine patch. Do not crush or give via NG

Cabergoline Rotigotine equivalent dose
0.5mg 2mg
0.5mg 2mg
1mg 4mg
2mg 6mg
3mg 8mg
4mg 12mg
5mg 16mg
6mg 16mg

Section 3 – Apomorphine pumps

Apomorphine (Apo-go) subcut infusion – This should only be instigated under the guidance of a PD specialist. It is not suitable for emergency administration in a drug-naïve patient. If a patient already on apomorphine is admitted this can be continued – contact Pulteney ward nursing staff for advice regarding setting up the pump (including during out of hours).

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