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Dopamine Agonist

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Dopamine Agonist, Non-ergot Dopamine Agonist, Ergot Dopamine Agonist

  1. General: Parkinson's Disease related concerns
    1. Less effective than Sinemet, but are less associated with Dyskinesias
    2. Most effective agents at reducing Sinemet off-time
    3. Increased Sleepiness, edema, Nausea and Hallucinations
  2. Dosing
    1. Start at low dose and may titrate to symptom control every 5-7 days
    2. When stopping agents, taper off over 2-3 weeks
  3. Pramipexole (Mirapex)
    1. Immediate Release start 0.125 mg three times daily (may increase by 0.125-0.25 mg/week up to 4.5 mg/day)
    2. Extended Release start 0.375 mg daily (may increase by 0.75 mg/week up to 4.5 mg/day)
    3. Half life: 7-17 hours
    4. Minimal metabolism
  4. Ropinirole (Requip)
    1. Immediate Release start 0.25 mg three times daily (may increase by 0.25 mg/week up to 24 mg/day)
    2. Extended Release start 2 mg daily (may increase by 2 mg/week up to 24 mg/day)
    3. Half life: 6 hours
    4. Hepatic metabolism
  5. Rotigotine (Neupro) transdermal patch
    1. Apply once daily (available in 1, 2, 3, 4, 6 and 8 mg)
    2. One patch applied daily to a new site
    3. Do not repeat the same site for 14 days
    4. Start at 2 mg/24 hours
    5. May increase weekly to a maximum of 8 mg/24 h
  6. Apomorphine
    1. Dopamine Agonist prn for off-time and severe motor freezing episodes
    2. Start at low dose with first dose in neurology office with Blood Pressure and pulse monitoring
    3. Give with Antiemetic (NOT Zofran due to interaction causing Hypotension, Syncope)
    4. Titrate to effective dose every few days
    5. Preparations
      1. Apomorphine SQ Injection (Apokyn) (30 mg/3 ml) pen in marked in ml (not mg)
      2. Apomorphine Sublingual Film (Kynmobi)
  7. Non-ergot Dopamine Agonists
    1. Effective control of motor symptoms with reduced of-time
    2. Adverse effects include Somnolence, hallucations, decreased impulse control
    3. Dosing
      1. Start at low dose and may titrate to symptom control every 5-7 days
      2. When stopping agents, taper off over 2-3 weeks
    4. Pramipexole (Mirapex)
      1. Immediate Release start 0.125 mg three times daily (may increase by 0.125-0.25 mg/week up to 4.5 mg/day)
      2. Extended Release start 0.375 mg daily (may increase by 0.75 mg/week up to 4.5 mg/day)
    5. Ropinirole (Requip)
      1. Immediate Release start 0.25 mg three times daily (may increase by 0.25 mg/week up to 24 mg/day)
      2. Extended Release start 2 mg daily (may increase by 2 mg/week up to 24 mg/day)
    6. Rotigotine (Neupro) transdermal patch
      1. Apply once daily (available in 1, 2, 3, 4, 6 and 8 mg)
  1. Avoid these agents in Parkinson's Disease Management
  2. Diagnostics required when on Ergot Dopamine Agonists (baseline and annual)
    1. Echocardiogram
    2. Chest XRay
    3. Erythrocyte Sedimentation Rate (ESR)
    4. Renal Function tests
  3. Bromocriptine mesylate (Parlodel)
    1. Start at 1.25 mg PO bid
    2. Increase every 2 weeks to 5-20 mg PO bid
    3. Half life: 3-8 hours
    4. Hepatic metabolism
  4. Pergolide mesylate (Permax): Not recommended (not available in U.S.)
    1. Half life: 27 hours
    2. Hepatic metabolism
    3. Risk of valvular disease and Pulmonary Hypertension
      1. Van Camp (2004) Lancet 363:1179-83 [PubMed]
  • Adverse Effects
  1. Somnolence
  2. Hallucations
  3. Impulse control behaviors (uncommon)
    1. Behaviors seen with Dopamine Agonists include Compulsive Gambling, hypersexuality, shopping, eating
    2. Moore (2014) JAMA Intern Med 174(12):1930-3 [PubMed]