• Ensure that any requested changes to repeat medication have been made since the last specialist visit, and check that doses and timings are correct.
• Check that any relevant drug monitoring has been undertaken if there is a local agreement for monitoring to take place in primary care.
• Ask about and monitor adherence to treatment and explore any barriers to taking medication.
• If the person is over-using dopaminergic medication, consider whether they may have dopamine dysregulation syndrome (compulsive overuse of dopaminergic drugs) — see Impulse control and related disorders.
• The National Institute for Health and Clinical Excellence has issued guidance on Medicines adherence that can be found at www.nice.org.uk.
• Ask about possible adverse effects of anti-parkinsonian medication.
• Ensure that no other medication is exacerbating the Parkinson's disease — see Drugs to avoid.
• Do not stop anti-parkinsonian medication abruptly because of the risk of causing neuroleptic malignant syndrome (which can be serious).
• Respond to any concerns about motor or non-motor symptoms of Parkinson's disease.
• Check that the person has appropriate access to support services — see Role of primary care.

• Arrangements for monitoring may vary depending on local agreements between primary and secondary care.
• The following medications require monitoring — see Drug monitoring for further details:
• Ergot-derived dopamine agonists (cabergoline, pergolide, and bromocriptine).
• The catechol-O-methyl transferase (COMT) inhibitor, tolcapone.
• Apomorphine.

Changes to repeat medication

• This recommendation is based on a retrospective survey (published as a research letter) which found that 29% of medication changes recommended at specialist outpatient clinic appointments were not completed [Ng et al, 2007]. The authors do, however, acknowledge that there may be abundant reasons for this level of non-completion.

Drug monitoring

• This recommendation is pragmatic.

Adherence to treatment

• The recommendation to monitor adherence to treatment is based on expert opinion in a Parkinson's Disease Society publication, The professionals guide to Parkinson's disease [Parkinson's Disease Society, 2007].
• The recommendation to explore any barriers to taking medication is based on the The National Service Framework for long term conditions, which also states that 50% of people do not take their prescribed medication [DH, 2005].
• The recommendation to consider dopamine dysregulation syndrome if the person is over-using dopaminergic medication is based on case reports described in an evidence-based narrative review [Lim et al, 2008].

Drugs to avoid

• The recommendation to ensure that no other medication is exacerbating the Parkinson's disease is based on expert opinion expressed in a Parkinson's Disease Society publication, The professional's guide to Parkinson's disease [Parkinson's Disease Society, 2007].

Not stopping medication abruptly

• The recommendation to not stop anti-parkinsonian medication abruptly because of the risk of causing neuroleptic malignant syndrome (which can be serious) is based on expert opinion expressed in a Parkinson's Disease Society publication, The professional's guide to Parkinson's disease [Parkinson's Disease Society, 2007].

Adverse effects, motor and non-motor symptoms, and support services

• The recommendations to ask about possible adverse effects of anti-parkinsonian medication, monitor motor and non-motor symptoms (if possible), and check access to support services are pragmatic, and not related to any published evidence.