Share on Facebook
Share on Twitter
Share on LinkedIn
Share by Email
Print
Parkinsonism Treatments
| PARKINSONISM TREATMENTS | ||||
|---|---|---|---|---|
| Generic | Brand | Strength | Form | Adult Dose |
| ADENOSINE RECEPTOR ANTAGONIST | ||||
| istradefylline | Nourianz | 20mg, 40mg | tabs | 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 | — | 0.5mg, 1mg, 2mg | scored tabs |
Initially 0.5−1mg at bedtime. May increase by 0.5mg at 5−6 day intervals; max 6mg daily. |
| 1mg/mL | soln for IM or IV inj | |||
| trihexy– phenidyl |
— | 2mg, 5mg | scored tabs | 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. |
| 2mg/5mL | susp | |||
| CATECHOL O-METHYL TRANSFERASE (COMT) INHIBITORS | ||||
| entacapone | Comtan | 200mg | tabs | 200mg with each dose of L‑dopa/carbidopa, up to 8 times daily |
| opicapone | Ongentys | 25mg, 50mg | caps | Avoid food for 1hr before and ≥1hr after dose. 50mg once daily at bedtime. Hepatic impairment (moderate): 25mg once daily at bedtime; (severe): avoid. |
| tolcapone | Tasmar | 100mg | tabs | 100mg three times daily; may cautiously increase to 200mg three times daily. |
| CHOLINESTERASE INHIBITORS | ||||
| rivastigmine | — | 1.5mg, 3mg, 4.5mg, 6mg | caps | 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. |
| Exelon | 4.6mg/ 24hrs, 9.5mg/ 24hrs, 13.3mg/ 24hrs |
patches | 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 | 25mg | tabs | 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* |
Dhivy | 25mg/ 100mg |
functionally scored tabs | Initially one tab 3 times daily; may increase by up to one whole tab every day or every other day as needed; max 8 whole tabs daily. |
| Duopa | 4.63mg/ 20mg per mL |
enteral susp | 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 | 23.75mg/ 95mg, 36.25mg/ 145mg, 48.75mg/ 195mg, 61.25mg/ 245mg |
ext-rel caps | 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 | |
| — | 10mg/ 100mg, 25mg/ 100mg, 25mg/ 250mg |
ODT | 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 | 10mg/ 100mg, 25mg/ 100mg, 25mg/ 250mg |
tabs | ||
| carbidopa/ levodopa ER |
— | 25mg/ 100mg, 50mg/ 200mg+ |
ext-rel tabs | 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 | — | 100mg | tabs | 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. |
| 50mg/5mL | susp | |||
| Gocovri | 68.5mg, 137mg | ext-rel caps | Adjunct to levodopa/carbidopa: initially 137mg once daily at bedtime; increase to 274mg once daily at bedtime after 1 week. Renal impairment (CrCl 30–59mL/min/1.73m2): initially 68.5mg once daily; increase to max 137mg once daily after 1 week; (CrCl 15–29mL/min/1.73m2): 68.5mg once daily. | |
| Osmolex ER | 129mg, 193mg | ext-rel tab | 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 | 10mg/mL | soln for SC inj | Premedicate with trimethobenzamide (300mg 3 times daily) starting 3 days prior to Apokyn initiation; alternatively, consider starting Apokyn at 0.1mL (1mg) and titrate based on response. Supervise 1st dose (monitor BP); prescribe for outpatient use at a dose at least 0.1mL less than tolerated test dose; usual range 0.1mL to 0.6mL; max 0.6mL/episode and one dose/episode; usual max 5 doses/day (2mL/day). Restart at 0.2mL/dose and re-titrate if therapy interrupted for >1 week. Mild or moderate renal impairment: reduce test and start doses to 0.1mL. |
| Kynmobi | 10mg, 15mg, 20mg, 25mg, 30mg | SL films | Consider premedication with trimethobenzamide (300mg 3 times daily) starting 3 days prior to apomorphine initiation. Supervise 1st dose (monitor BP and pulse). Initially 10mg; if tolerated and effective, give up to max 5 times daily (as needed basis). If insufficient response, increase by 5mg increments and continued generally within 3 days, then reevaluate. Usual range: 10–30mg/dose. Separate doses by at least 2hrs. Max 30mg/single dose. | |
| bromocrip– tine |
Parlodel | 5mg | caps | Initially 1.25mg twice daily. May increase every 2−4wks by 2.5mg/day; max 100mg/day. |
| 2.5mg | scored tabs | |||
| prami– pexole* |
— | 0.125mg, 0.25mg+, 0.5mg+, 0.75mg, 1mg+, 1.5mg+ | tabs | 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 | 0.375mg, 0.75mg, 1.5mg, 2.25mg, 3mg, 3.75mg, 4.5mg | ext‑rel tabs | 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* | — | 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg | tabs | 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. ESRD on dialysis: initially 0.25mg 3 times daily; max 18mg/day. |
| — | 2mg, 4mg, 6mg, 8mg, 12mg | ext‑rel tabs | 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). ESRD on dialysis: initially 2mg once daily; max 18mg/day. | |
| rotigotine | Neupro | 1mg/24hrs, 2mg/24hrs, 3mg/24hrs, 4mg/24hrs, 6mg/24hrs, 8mg/24hrs | patches | 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 | 12.5mg/ 50mg/ 200mg, 18.75mg/ 75mg/ 200mg, 25mg/ 100mg/ 200mg, 31.25mg/ 125mg/ 200mg, 50mg/ 200mg/ 200mg, 37.5mg/ 150mg/ 200mg |
tabs | 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 | 42mg | caps | 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 | 0.5mg, 1mg | tabs | 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 | 50mg, 100mg | tabs | 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 | — | 5mg | caps | 5mg at breakfast and at lunch; max 10mg/day. After 2−3 days, L‑dopa/carbidopa dosage may be reduced by 10−30%. |
| Zelapar | 1.25mg | ODT | 1.25mg once in the AM for at least 6wks; if needed, may increase to max 2.5mg once daily if tolerated | |
| NOTES | ||||
|
Key: + = scored tablets; amps = ampules; ext-rel tabs = extended release tablets; ODT = orally disintegrating tablets; SL = sublingual; soln = solution; susp = suspension; sust-rel tabs = sustained release 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. 4/2023) |
||||
