II. Preparations: Non-ergot Dopamine Agonists (as dosed in Parkinson's Disease)
-
General: Parkinson's Disease related concerns
- Less effective than Levodopa, but are less associated with Dyskinesias
- Most effective agents at reducing Levodopa off-time
- Increased Sleepiness, edema, Nausea and Hallucinations
- Dosing
- Start at low dose and may titrate to symptom control every 5-7 days
- When stopping agents, taper off over 2-3 weeks
-
Pramipexole (Mirapex)
- Immediate Release start 0.125 mg three times daily (may increase by 0.125-0.25 mg/week up to 4.5 mg/day)
- Extended Release start 0.375 mg daily (may increase by 0.75 mg/week up to 4.5 mg/day)
- Half life: 7-17 hours
- Minimal metabolism
-
Ropinirole (Requip)
- Immediate Release start 0.25 mg three times daily (may increase by 0.25 mg/week up to 24 mg/day)
- Extended Release start 2 mg daily (may increase by 2 mg/week up to 24 mg/day)
- Half life: 6 hours
- Hepatic metabolism
-
Rotigotine (Neupro) transdermal patch
- Apply once daily (available in 1, 2, 3, 4, 6 and 8 mg)
- One patch applied daily to a new site
- Do not repeat the same site for 14 days
- Start at 2 mg/24 hours
- May increase weekly to a maximum of 8 mg/24 h
-
Apomorphine
- Dopamine Agonist prn for off-time and severe motor freezing episodes
- Start at low dose with first dose in neurology office with Blood Pressure and pulse monitoring
- Give with Antiemetic (NOT Zofran due to interaction causing Hypotension, Syncope)
- Titrate to effective dose every few days
- Preparations
- Apomorphine SQ Injection (Apokyn) (30 mg/3 ml) pen in marked in ml (not mg)
- Apomorphine Sublingual Film (Kynmobi)
III. Preparations: Ergot Dopamine Agonists (as dosed in Parkinson's Disease)
- Avoid these agents in Parkinson's Disease Management
- Diagnostics required when on Ergot Dopamine Agonists (baseline and annual)
-
Bromocriptine
Mesylate (Parlodel)
- Start at 1.25 mg PO bid
- Increase every 2 weeks to 5-20 mg PO bid
- Half life: 3-8 hours
- Hepatic metabolism
- Pergolide Mesylate (Permax): Not recommended (not available in U.S.)
- Half life: 27 hours
- Hepatic metabolism
- Risk of valvular disease and Pulmonary Hypertension
IV. Adverse Effects
-
Somnolence
- Risk of sudden onset of sleep without warning ("Sleep Attacks")
- Hallucations
- Impulse control behaviors (uncommon)
- Behaviors seen with Dopamine Agonists include Compulsive Gambling, hypersexuality, shopping, eating
- Moore (2014) JAMA Intern Med 174(12):1930-3 [PubMed]
V. References
- Ahlskog (2011) Mayo Internal Medicine Review Lecture
- Schim (2001) CMEA Medicine Lecture, San Diego
- Clarke (2003) Clin Evid 10:1582-98 [PubMed]
- Clarke (2004) Lancet Neurol 3:466-74 [PubMed]
- Gazewood (2013) Am Fam Physician 87(4): 267-73 [PubMed]
- Nutt (2005) N Engl J Med 353:1021-7 [PubMed]
- Olanow (2001) Neurology 56:S1-88 [PubMed]
- Rao (2006) Am Fam Physician 74:2046-56 [PubMed]
- Young (1999) Am Fam Physician 59(8):2155-67 [PubMed]