Parkinsonism Drug Treatment
| PARKINSONISM DRUG TREATMENT | ||||
|---|---|---|---|---|
| Generic | Brand | Formulations/Strengths | Usual Adult Dose¹ | |
| ANTICHOLINERGICS | ||||
| benztropine | Cogentin |
Scored tabs: 0.5mg, 1mg, 2mg Amps: 1mg/mL |
Initially 0.5–1mg at bedtime. May increase by 0.5mg at 5–6 day intervals; max 6mg daily. | |
| hyoscyamine sulfate | NuLev |
Chewable melt tabs: 0.125mg |
1–2 tabs every 4hrs or as needed; max 12 tabs/day. | |
| trihexyphenidyl | — |
Scored tabs: 2mg, 5mg Susp: 2mg/5mL |
Give in 3–4 divided doses. 1mg on day 1, may increase by 2mg every 3–5 days; usual max 6–15mg/day. Concomitant L-dopa: 3–6mg/day and reduce L-dopa dose. | |
| CATECHOL O-METHYL TRANSFERASE INHIBITORS | ||||
| entacapone | Comtan |
Tabs: 200mg |
200mg with each dose of L-dopa/carbidopa, up to 8 times daily. | |
| tolcapone | Tasmar |
Tabs: 100mg |
100mg three times daily; may cautiously increase to 200mg three times daily. | |
| CHOLINESTERASE INHIBITORS | ||||
| rivastigmine | Exelon | Caps: 1.5mg, 3mg, 4.5mg, 6mg
Soln: 2mg/mL Patches: 4.6mg/24hrs Patches: 9.5mg/24hrs |
Initially 1.5mg twice daily; if tolerated, may increase by 1.5mg twice daily at
intervals of at least 4 weeks; max 12mg/day.
Patch: Initially apply one 4.6mg/24hrs patch once daily; if tolerated, may increase to 9.5mg/24hrs patch after 4 weeks at previous dose. |
|
| DOPA-DECARBOXYLASE INHIBITOR | ||||
| carbidopa | Lodosyn |
Tabs: 25mg |
Concomitant Sinemet 10-100: 25mg with first dose of Sinemet each day; additional 12.5mg or 25mg doses may be given with each dose of Sinemet. Concomitant Sinemet 25-100 or 25-250: 25mg with any dose of Sinemet as required for optimum therapeutic response. Max total carbidopa 200mg/day.¹ | |
| DOPA-DECARBOXYLASE INHIBITOR + DOPAMINE PRECURSOR | ||||
| carbidopa/levodopa* | Parcopa |
ODT: 10mg/100mg, 25mg/100mg, 25mg/250mg |
For Parcopa: Discontinue L-dopa at least 12hrs before. Initially one 25mg/100mg tab 3 times daily, or one 10mg/100mg tab 3–4 times daily; increase every 1–2 days up to 2 tabs (of either 25/100 or 10/100) 4 times daily. Patients taking L-dopa>1500mg/day: initially one 25mg/250mg tab 3–4 times daily; max carbidopa 200mg/day. | |
| Sinemet |
Tabs: 10mg/100mg, 25mg/100mg, 25mg/250mg |
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| carbidopa/levodopa CR* | Sinemet CR |
Sust-rel tabs: 25mg/100mg, 50mg/200mg† |
Not receiving L-dopa: Initially one 50mg/200mg tab twice daily, at intervals of at least 6hrs. Allow 3 days between dosage adjustments. If given at intervals <4hrs and/or divided doses not equal: give smaller doses at end of day. May add immediate-release Sinemet 25-100 or 10-100 tabs in advanced disease. | |
| DOPAMINE AGONISTS | ||||
| amantadine | — |
Tabs: 100mg Susp: 50mg/5mL |
Monotherapy: 100mg twice daily; may increase after 1–2 weeks by 100mg daily. Serious associated illness or high doses of other antiparkinson drugs: 100mg once daily, may increase after 1 to several weeks to 100mg twice daily; max 400mg/day in divided doses. Renal dysfunction: reduce dose; see literature. | |
| apomorphine | Apokyn |
Amps, Cartridges: 10mg/mL |
See literature¹
|
|
| bromocriptine | Parlodel | Caps: 5mg
Scored tabs: 2.5mg |
Initially 1.25mg twice daily. May increase every 2–4 weeks by 2.5mg/day; max 100mg/day. | |
| pramipexole* | Mirapex |
Tabs: 0.125mg, 0.25mg†, 0.5mg†, 0.75mg, 1mg†, 1.5mg† |
0.125mg three times daily. May increase gradually at intervals of 5–7 days up to max 1.5mg three times daily. Renal impairment (CrCl 30–50mL/min): 0.125mg twice daily; max 0.75mg three times daily. CrCl 15–<30mL/min: 0.125mg once daily; max 1.5mg once daily. CrCl <15mL/min, hemodialysis: not recommended. | |
| Mirapex ER |
Ext-rel tabs: 0.375mg, 0.75mg, 1.5mg, 2.25mg, 3mg, 3.75mg, 4.5mg |
0.375mg once daily; may increase gradually at intervals of 5–7 days, first to 0.75mg/day, then by 0.75mg increments up to max 4.5mg/day. Renal impairment (CrCl 30–50mL/min): give every other day; reevaluate before increasing to daily dosing after 1 week and before titrating by 0.375mg increments up to 2.25mg/day. CrCl <30mL/min, hemodialysis: not recommended. | ||
| ropinirole* | Requip |
Tabs: 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg |
0.25mg 3 times daily, then increase by 0.25mg 3 times daily at 1 week intervals to 1mg 3 times daily to 4th week. May increase by 1.5mg/day at 1 week intervals up to 9mg/day, then by up to 3mg/day at 1 week intervals to max 24mg/day. | |
| Requip XL |
Ext-rel tabs: 2mg, 4mg, 6mg, 8mg, 12mg |
2mg once daily for 1–2 weeks, then increase by 2mg/day at ≥1 week intervals to max 24mg/day. | ||
| rotigotine | Neupro |
Patches: 1mg/24hours, 2mg/24hours, 3mg/24hours, 4mg/24hours, 6mg/24hours, 8mg/24hours |
Early-stage: initially 2mg/24hrs patch once daily; may increase weekly by 2mg/24hrs if needed;
max 6mg/24hrs once daily.
Advanced-stage: initially 4mg/24hrs patch once daily; may increase weekly by 2mg/24hrs if needed; max 8mg/24hrs once daily. |
|
| DOPA-DECARBOXYLASE INHIBITOR + DOPAMINE PRECURSOR + CATECHOL O-METHYL TRANSFERASE INHIBITORS COMBINATION | ||||
| carbidopa/levodopa + entacapone | Stalevo |
Tabs: 50mg, 75mg, 100mg, 125mg, 150mg, 200mg |
See literature¹ | |
| MONOAMINE OXIDASE-B INHIBITORS | ||||
| rasagiline | Azilect |
Tabs: 0.5mg, 1mg |
Monotherapy: 1mg once daily. Adjunctive therapy: initially 0.5mg once daily; may increase to 1mg once daily (reduce L-dopa dose if side effects increase). Mild hepatic impairment (Child-Pugh score 5–6) or concomitant CYP1A2 inhibitors: 0.5mg once daily. | |
| selegiline | Eldepryl |
Caps: 5mg |
5mg at breakfast and at lunch; max 10mg/day. After 2–3 days, L-dopa/carbidopa dosage may be reduced by 10–30%. | |
| Zelapar |
ODT: 1.25mg |
1.25mg once in the AM for at least 6 weeks; if needed, may increase to max 2.5mg once daily if tolerated. | ||
| NOTES | ||||
|
*First line treatment for Parkinson's disease. ¹For additional dosing information, including titrations and recommendations, see product labeling. Caps = capsules; tabs = tablets; susp = suspension; ODT = orally disintegrating tablets; sust-rel tabs = sustained release tablets; ext-rel tabs = extended release tablets; soln = solution; amps = ampules; † = scored tablets. Adapted from Reuben DB, Herr KA, Pacala JT, et al. Geriatrics At Your Fingertips: 2005, 7th Edition. The American Geriatrics Society; 2005. (Rev. 2/2013) |
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