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Parkinson's disease - Management
How do I manage nausea and vomiting in people with Parkinson's disease?

For nausea or vomiting after starting or increasing the dose of a dopaminergic drug

  • Initially, if nausea is mild:
    • Reassure that nausea often settles over time as tolerance occurs.
    • Advise the person to take their medication with food.
      • Advise people taking levodopa not to increase their intake of high-protein foods.
  • If nausea persists or is more severe:
    • Prescribe domperidone, reducing or stopping it when the nausea or vomiting settles.
      • Do not use metoclopramide or prochlorperazine.
    • Consider seeking the advice of a specialist, who may recommend one or more of the following:
      • An increase in the proportion of decarboxylase inhibitor to levodopa (only feasible for co-careldopa).
      • A slower titration of the anti-parkinsonian drug.
      • A switch to an alternative.

For nausea or vomiting unrelated to medication

  • If an anti-emetic is required, use domperidone, reducing or stopping it when the nausea settles. Avoid metoclopramide or prochlorperazine.
Clarification / Additional information
  • See Other complications for background details about nausea and vomiting in people with Parkinson's disease.
  • The 5HT3 antagonists, granisetron, ondansetron, and topisetron, can also be used safely to treat nausea and vomiting in people with Parkinson's disease.
Basis for recommendation

These recommendations are mainly based on an evidence-based review, Adverse events from the treatment of Parkinson's disease [Chou, 2008], and on a publication by the Parkinson's Disease Society, The professionals guide to Parkinson's disease, which is likely to represent expert opinion [Parkinson's Disease Society, 2007].

  • Summaries of Product Characteristics of the available anti-parkinsonian drugs state that they can all be taken with food (see the Electronic Medicines Compendium), although a narrative review stated that co-administration with food should only be undertaken for a short period because food can reduce absorption, resulting in reduced efficacy and increased risk of motor fluctuations [Chou, 2008]. However, the manufacturers state that rates and extents of absorption are minimally reduced. For example, the manufacturers of Madopar® (co-beneldopa) state that food can reduce the rate of absorption of levodopa by 15%, and yet they still advise that the drug should be taken with or after food.
  • There are case reports of levodopa preparations taken with high-protein foods or supplements resulting in reduced response or worsening motor symptoms [Micromedex, 2009].

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