What anesthetic medications should be avoided in patients with Parkinson’s disease?

Anesthetic Medications to Avoid in Parkinson's Disease

Avoid antipsychotics (except quetiapine, clozapine, or pimavanserin), benzodiazepines, anticholinergics, metoclopramide, and droperidol in patients with Parkinson's disease, as these medications can precipitate severe motor deterioration, drug-induced parkinsonism, or mask neurological symptoms.

High-Priority Medications to Avoid

Antipsychotics and Dopamine Antagonists

• Most antipsychotics are contraindicated due to dopamine receptor blockade that worsens parkinsonian symptoms 1
• The only acceptable antipsychotics for Parkinson's patients are quetiapine, clozapine, and pimavanserin - all other antipsychotics should be avoided 1
• Metoclopramide is particularly dangerous as it causes extrapyramidal signs including acute dystonic reactions, drug-induced parkinsonism, akathisia, and tardive dyskinesia 1
• Droperidol should be avoided as an antiemetic due to its antidopaminergic effects 2, 3

Benzodiazepines

• Benzodiazepines should be avoided as they increase risk of delirium, falls, fractures, cognitive impairment, and dependence in older adults 1
• These agents can mask neurological symptoms and exacerbate postoperative confusion 1
• Avoid benzodiazepines for first-line treatment of perioperative delirium unless benefits clearly outweigh risks 1

Anticholinergic Medications

• Anticholinergics including atropine and antihistamines (such as cyclizine) precipitate delirium and should be avoided 1
• These medications are particularly problematic in elderly patients with neurodegenerative disease 1

Analgesic Considerations

Opioids - Use With Extreme Caution

• Pethidine (meperidine) should be completely avoided due to high risk of delirium and adverse CNS effects 1
• Morphine, fentanyl, and oxycodone are not specifically contraindicated but require careful titration to minimal effective doses 1
• High opioid doses significantly increase delirium risk, particularly in patients with preexisting neurological disease 1

Multimodal Analgesia Strategy

• Prioritize paracetamol as first-line therapy for postoperative pain 1
• Use NSAIDs cautiously at lowest doses with proton pump inhibitor protection and renal monitoring 1
• Regional anesthesia and local anesthetic blocks are preferred to minimize systemic medication exposure 1, 4

Medications Requiring Caution

Sedative-Hypnotics and Corticosteroids

• Sedative hypnotics and corticosteroids can precipitate delirium and should be avoided when possible 1
• These agents may mask parkinsonian symptoms intraoperatively and cause postoperative exacerbation 4, 2

Gabapentinoids

• Consider risks versus benefits carefully before using gabapentinoids in older adults with Parkinson's disease 1
• Recent evidence shows minimal pain benefit but increased dizziness and visual disturbance 1

Critical Perioperative Management Principles

Medication Timing

• Continue antiparkinsonian medications throughout the perioperative period without interruption 2, 5, 3
• Ensure levodopa is administered at least 30 minutes before meals to optimize absorption 6
• Separate levodopa from iron and calcium supplements by at least 2 hours 6

Anesthetic Technique Selection

• Spinal or regional anesthesia may be advantageous as it avoids muscle relaxants and allows clinical distinction of neurological symptoms 4
• General anesthesia can mask neurological symptoms intraoperatively and exacerbate them postoperatively 4, 2
• With regional techniques, neurological symptoms are not masked by muscle relaxation 4

Common Pitfalls to Avoid

• Do not confuse drug-induced parkinsonism with disease progression - metoclopramide and antipsychotics can cause acute worsening 1
• Do not withhold antiparkinsonian medications perioperatively - this causes severe motor deterioration 2, 5, 3
• Do not use typical antiemetics - ondansetron is preferred over metoclopramide or droperidol 1, 2
• Do not assume all movement disorders are parkinsonian tremor - distinguish myoclonus, akathisia, and restless legs syndrome 6