AAN GUIDELINES Bundle

Table 3. Pharmacotherapeutic Options for Symptomatic Treatment of Parkinson Disease Drug Dosage Form Recommended Dosage Comments MAO-B inhibitors rasagiline Azilect 0.5, 1 mg tablets Monotherapy: 1 mg/d Adjunctive: 0.5 mg/d; if insufficient clinical response, may be increased to 1 mg/d > Monotherapy or adjunct to levodopa therapy > Contraindicated with concomitant use of dextromethorphan, MAOIs, meperidine and other opioids, methadone, propoxyphene, tramadol > Avoid dietary sympathomimetic amines, tyramine, SNRI and SSRI antidepressants, TCAs > Use low tyramine diet > Not associated with increased melanoma risk specifically, but patients should undergo periodic dermatological screening selegiline (l-deprenyl) Eldepryl, generics 5 mg capsule 10 mg/d divided 5 mg at breakfast and lunch; max 10 mg/d > Adjunct to carbidopa/levodopa therapy; if levodopa associated side effects exacerbated, consider reducing dose of carbidopa/levodopa by 10–30% > Contraindicated with concomitant use of meperidine and other opioids > Avoid amitriptyline, protriptyline, MAOIs, SSRIs,TCAs orally disintegrating selegiline Zelapar 1.25 mg orally disintegrating tablet (not swallowed) 1.25 mg q am (before breakfast and without liquid) for 6 wk; thereafter may be increased to 2.5 mg q am; max 2.5 mg/d > Adjunct to carbidopa/levodopa therapy if deteriorating response to therapy > Contraindicated with concomitant use of dextromethorphan, MAO inhibitors, and selective MAO-B inhibitors, meperidine, and other analgesics including tramadol, methadone and propoxyphene > Avoid SSRIs, TCAs > Not associated with increased melanoma risk specifically, but patients should undergo periodic dermatological screening > Delivers more active drug at a lower dose through bypassing the gut and first pass hepatic metabolism Dopamine agonists apomorphine Apokyn 10 mg/mL in 3 mL cartridge Initial: 0.2 mL SQ injection; titrate up (based on effectiveness/tolerance) to max 6 doses/d prn > Adjunct to levodopa and other medication therapy for "wearing off" episodes; may cause dyskinesia or exacerbate pre-existing dyskinesia > Contraindicated in concomitant use of 5HT2 antagonists > Caution with drugs prolonging QT/QTc interval, mild–moderate hepatic or renal impairment > Somnolence/sudden sleep onset, orthostatic hypotension, hallucinations > Pretreat nausea/vomiting with antiemetic trimethobenzamide (antiemetics with anti-dopaminergic actions can worsen clinical state of Parkinson disease) bromocriptine Parlodel 2.5 mg tablet 5 mg capsule 1 2 of 2.5 mg tablet bid with meals; titrate up q 14–28 d by 2.5 mg/d to max 100 mg/d > Adjunct to carbidopa/levodopa therapy; efficacy > 2 yr not established > Contraindicated in uncontrolled hypertension, pregnancy, postpartum cardiovascular disease, concomitant use with ergot alkaloids > Somnolence/sudden sleep onset, orthostatic hypotension > Rarely used in clinical practice pergolide* Permax 0.05, 0.25, 1 mg tablets 0.05 mg/d first 2 d; titrate up 0.1–0.15 mg/d (divided doses tid) q 3 d for 12 d, then by 0.25 mg/d q 3 d to max 5 mg/d > Adjunct to carbidopa/levodopa therapy > Somnolence/sudden sleep onset, orthostatic hypotension, hallucinations > Monitor with echocardiogram due to concerns of cardiac valvular fibrosis pramipexole Mirapex 0.125, 0.25, 0.5, 1.0, 1.5 mg tablets 0.125 mg tid for 1 wk; titrate up each wk for 6 wk with 0.25, 0.5, 0.75, 1.0, 1.25, 1.5 mg tid > Monotherapy or adjunct to levodopa therapy > Titrate dosage to achieve max therapeutic effect against side effects of dyskinesia, hallucinations, somnolence/sudden sleep onset, dry mouth > Not associated with increased melanoma risk specifically, but patients should undergo periodic dermatological screening > Discontinue gradually over 1 wk ropinirole Requip Requip XL 0.25, 0.5, 1, 2, 3, 4, 5 mg tablets 2, 4, 6, 8, 12 mg 0.25 mg tid for 1 wk; then titrate up each wk to 9 mg/d by week 8, then by 3 mg/d to 24 mg/d 2 mg qd for 1-2 wk; increases of 2 mg/d at 1 wk or longer intervals to 24 mg/d > Monotherapy or adjunct to levodopa > Somnolence/sudden sleep onset, orthostatic hypotension, hallucinations > Not associated with increased melanoma risk specifically, but patients should undergo periodic dermatological screening > Discontinue by reducing dosage from tid to bid for 4 d, then once daily for 3 d before withdrawal

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