Parkinsonism Treatments
PARKINSONISM TREATMENTS
Generic Brand Form Strength Adult Dose
ADENOSINE RECEPTOR ANTAGONIST
istradefylline Nourianz tabs 20mg, 40mg 20mg once daily. May increase to max 40mg once daily, if needed and tolerated. Concomitant strong CYP3A4 inhibitors: max 20mg once daily. Moderate hepatic impairment: max 20mg once daily; monitor closely. Smokers (≥20 cigarettes/day): 40mg once daily.
ANTICHOLINERGICS
benztropine scored 
tabs
0.5mg, 1mg, 2mg Initially 0.5−1mg at bedtime. May increase by 0.5mg at 5−6 day intervals; max 6mg daily.
Cogentin amps 1mg/mL
hyoscy
amine sulfate
NuLev chew
able melt tabs
0.125mg 1−2 tabs every 4hrs or as needed; max 12 tabs/day
trihexy
phenidyl
scored tabs 2mg, 5mg 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.
susp 2mg/5mL
CATECHOL O-METHYL TRANSFERASE (COMT) 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 Initially 1.5mg twice daily (AM & PM); if tolerated, may increase by 1.5mg twice daily at intervals of at least 4 weeks. Usual range: 3–12mg/day; max 12mg/day.
patches 4.6mg/
 
24hrs, 9.5mg/
 
24hrs, 13.3mg/
 
24hrs
Initially apply one 4.6mg/24hrs patch once daily; if tolerated, may increase to 9.5mg/24hrs patch after 4 weeks at previous dose; can further increase to max 13.3mg/24hrs 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.
DOPA-DECARBOXYLASE INHIBITOR + DOPAMINE PRECURSOR
carbidopa/
levodopa*
Duopa enteral susp 4.63mg/
 
20mg per mL
Day 1: calculate and administer initial daily (Morning Dose + Continuous Dose); titrate subsequent doses based on response. Max daily dose: 2000mg of levodopa (1 cassette) over 16hrs. See full labeling.
Rytary ext-rel caps 23.75mg/
 
95mg, 36.25mg/
 
145mg, 48.75mg/
 
195mg, 61.25mg/
 
245mg
Levodopa-naive: Initially 23.75mg/95mg 3 times daily for the first 3 days; may increase to 36.25mg/145mg 3 times daily on the 4th day; up to max 97.5mg/390mg 3 times daily. May increase to max 5 times daily if more frequent dosing needed and tolerated. Max daily dose: 612.5mg/2450mg
ODT 10mg/
 
100mg, 25mg/
 
100mg, 25mg/
 
250mg
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. For ODT: Discontinue levodopa at least 12hrs before.
Sinemet tabs 10mg/
 
100mg, 25mg/
 
100mg, 25mg/
 
250mg
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 Monotherapy: 100mg twice daily; may increase after 1−2wks 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 full labeling.
susp 50mg/5mL
Osmolex ER ext-rel tab 129mg, 193mg, 258mg Initially 129mg once daily in the AM; may increase in weekly intervals to max 322mg once daily in the AM. Renal impairment (CrCl 30–59mL/min): initially 129mg once every 48hrs; increase every 3wks to max 322mg; (CrCl 15–29mL/min): initially 129mg once every 96hrs; increase every 4wks to max 322mg.
apomor
phine
Apokyn car
tridges
10mg/mL Supervise 1st dose (monitor BP); prescribe for outpatient use at a dose at least 0.1mL less than tolerated test dose; usual range 0.2mL to 0.6mL; max 0.6mL/episode and one dose/episode; usual max 5 doses/day (2mL/day). See full labeling.
bromocrip
tine
Parlodel caps 5mg Initially 1.25mg twice daily. May increase every 2−4wks by 2.5mg/day; max 100mg/day.
scored tabs 2.5mg
prami
pexole*
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 1wk 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 1wk intervals to 1mg 3 times daily to 4th week. May increase by 1.5mg/day at 1‑wk intervals up to 9mg/day, then by up to 3mg/day at 1‑wk intervals to max 24mg/day.
Requip XL ext‑rel tabs 2mg, 4mg, 6mg, 8mg, 12mg 2mg once daily for 1–2wks, then increase by 2mg/day at ≥1wk intervals up to max 24mg/day (for advanced disease: usually up to max 8mg/day; early disease: usually up to max 12mg/day).
rotigotine Neupro patches 1mg/24hrs, 2mg/24hrs, 3mg/24hrs, 4mg/24hrs, 6mg/24hrs, 8mg/24hrs 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 + COMT INHIBITORS
carbidopa/
levodopa/
entacapone
Stalevo tabs 12.5mg/
 
50mg/
 
200mg, 18.75mg/
 
75mg/
 
200mg, 25mg/
 
100mg/
 
200mg, 31.25mg/
 
125mg/
 
200mg, 50mg/
 
200mg/
 
200mg, 37.5mg/
 
150mg/
 
200mg
Max 1 tab per dosing interval. Previously on carbidopa/ levodopa and entacapone: Substitute on a mg/mg basis. Stalevo 50, 75, 100, 125, 150: max 8 tabs/day; Stalevo 200: max 6 tabs/day.
DOPAMINE PRECURSOR
levodopa Inbrija caps 42mg Inhale contents of 2 caps (84mg) as needed, up to 5 times daily. Max dose per OFF period: 84mg; max daily dose: 420mg.
MONOAMINE OXIDASE-B INHIBITORS
rasagiline Azilect tabs 0.5mg, 1mg Monotherapy or adjunct w/o levodopa: 1mg once daily. Concomitant levodopa with/without other PD drugs (eg, dopamine agonist, amantadine, anticholinergics): Initially 0.5mg once daily; may increase to 1mg once daily (consider reducing levodopa dose based on response). Mild hepatic impairment (Child-Pugh score 5−6) or concomitant CYP1A2 inhibitors: 0.5mg once daily.
safinamide Xadago tabs 50mg, 100mg Adjunct to levodopa/carbidopa: Initially 50mg once daily; may increase to 100mg once daily after 2wks as tolerated. Moderate hepatic impairment (Child-Pugh B): max 50mg once daily.
selegiline 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 6wks; if needed, may increase to max 2.5mg once daily if tolerated
NOTES

Key: susp = suspension; ODT = orally disintegrating tablets; sust‑rel tabs = sustained release tablets; ext‑rel tabs = extended release tablets; soln = solution; amps = ampules; + = scored tablets

*First line treatment for Parkinson’s disease.

Not an inclusive list of medications and/or official indications. Please see drug monograph at www.eMPR.com and/or contact company for full drug labeling.

(Rev. 2/2020)