What alternatives can be used for a hospice patient with declining health who can no longer take Sinemet (levodopa/carbidopa) tablets for Parkinson's disease symptom management?

Alternative Routes of Administration for Carbidopa-Levodopa in Hospice Patients

For hospice patients who can no longer swallow Sinemet (carbidopa-levodopa) tablets, the most appropriate alternative is to use a liquid formulation prepared by dissolving crushed tablets in ascorbic acid solution.

Liquid Formulation Preparation

When a hospice patient can no longer swallow tablets but still requires symptom management for Parkinson's disease, the following approach is recommended:

1. Preparation of liquid carbidopa-levodopa solution:

   • Crush the patient's prescribed Sinemet tablets in a glass, ceramic, or marble mortar
   • Dissolve 1 gram of vitamin C (ascorbic acid) in 500cc of cold water
   • Add the crushed Sinemet powder to the solution and stir until dissolved
   • Store in the refrigerator in an opaque or aluminum foil-covered bottle 1
   • Administer using a measuring cup, syringe, or medicine dropper

2. Dosing considerations:

   • Maintain the same total daily dose as previously prescribed tablets
   • Divide into smaller, more frequent doses if needed for better symptom control
   • The solution maintains a concentration of levodopa/carbidopa/ascorbic acid at 1/0.25/2 mg/ml 1

Alternative Options

If the liquid formulation is not feasible or effective, consider:

1. Orally disintegrating tablets (ODTs):

   • Can be placed on the tongue without water
   • Dissolve rapidly in the mouth
   • Shown to be preferred by 45% of Parkinson's patients compared to 20% who preferred conventional tablets 2
   • Particularly useful for patients with swallowing difficulties but who still have some oral function

2. Transdermal or duodenal options (may require specialist consultation):

   • Duodenal infusion of levodopa/carbidopa (requires placement of feeding tube)
   • Transdermal levodopa patch (may not be widely available) 3

Symptom Management Approach

For declining hospice patients with Parkinson's disease:

1. Prioritize symptom management:

   • Focus on controlling rigidity, tremor, and akinesia which impact comfort
   • Maintain carbidopa-levodopa therapy as it remains the most potent dopaminergic therapy 3
   • Consider adjunctive medications for specific symptoms

2. For sleep disturbances:

   • Consider trazodone (25-100 mg PO at bedtime)
   • Alternatives include olanzapine (2.5-5 mg at bedtime) or quetiapine (2.5-5 mg at bedtime) 4
   • For patients with restless leg syndrome, maintain carbidopa-levodopa therapy 4

3. For anxiety/agitation:

   • Consider lorazepam 0.5-1 mg as needed
   • For severe agitation, consider antipsychotics like haloperidol or chlorpromazine 4

Common Pitfalls to Avoid

1. Abrupt discontinuation: Never abruptly stop carbidopa-levodopa therapy, as this can cause severe worsening of symptoms and distress

2. Inadequate symptom control: Underdosing due to concerns about administration route can lead to increased rigidity and discomfort

3. Medication interactions: Be cautious with antiemetics like metoclopramide which can worsen Parkinson's symptoms 4

4. Overtreatment: As the patient declines, focus on comfort rather than perfect symptom control

Family Education

Provide clear instructions to family and caregivers about:

• How to prepare and administer the liquid medication
• Signs of under-treatment (increased rigidity, tremor)
• Signs of over-treatment (confusion, hallucinations)
• Reassurance that maintaining this medication is important for the patient's comfort

Remember that the goal in hospice care is to prioritize comfort and quality of life. Maintaining carbidopa-levodopa therapy in an alternative form helps prevent distressing symptoms that would significantly impact the patient's remaining time.