4.9.1.1 Dopamine receptor agonists

ChoiceDrugDosage
1st choice

Oral preparations
Ropinirole tablets 250 micrograms, 500 micrograms, 1mg, 2mg 5mg; ropinirole tablets m/r 2mg, 4mg, 8mg
Dose:
See BNF - seek specialist advice
Or

Pramipexole tablets 88 micrograms, 180micrograms, 350micrograms, 700micrograms; pramipexole tablets m/r 260micrograms, 520micrograms, 1.05mg, 1.57mg, 2.1mg, 2.62mg, 3.15mg

Strengths stated in terms of pramipexole base

Dose:
See BNF - seek specialist advice
Transdermal preparations

Specialist initiation
Rotigotine transdermal patches 1mg/24 hours, 2mg/24 hours, 3mg/24 hours, 4mg/24 hours, 6mg/24 hours, 8mg/24 hoursDose:
See BNF - seek specialist advice

Prescribing Notes

  • Ropinirole or pramipexole can be used as monotherapy or adjunctive therapy with levodopa.
  • Rotigotine patches may be useful in patients with complicated oral regimes and in those with delayed gastric emptying or swallow problems or where there are predominant nocturnal symptoms.
  • Ergot derivatives (bromocriptine, cabergoline and pergolide) are no longer recommended. They have rarely been associated with pulmonary, retroperitoneal, pericardial and valvular fibrotic reactions and require regular clinical monitoring – see MHRA.
  • Dopamine receptor agonists are emetogenic. Nausea will often settle over time as tolerance occurs.  If nausea is persistent or severe:
    • Do not use metoclopramide or prochlorperazine
    • Domperidone can be prescribed, reducing or stopping it when the nausea or vomiting settles. Domperidone is associated with a small increased risk of serious cardiac side effects. Its use is now restricted to the relief of symptoms of nausea and vomiting and the dosage and duration of use have been reduced. Treatment should generally only be given for up to one week. Domperidone is now contraindicated in those with underlying cardiac conditions and other risk factors. Risks are higher in people older than 60 years. For further information see MHRA.
  • When used as adjunctive therapy, dopamine receptor agonists can exacerbate levodopa-induced adverse effects.
  • All dopamine receptor agonists can cause postural hypotension and neuropsychiatric adverse effects.
  • Apomorphine is a powerful dopamine receptor agonist that must be given subcutaneously, either by infusion or on an “as required” basis. It is approved for use under a shared care guideline.
  • Amantadine is not a first choice treatment but it may be an option for some patients where dyskinesia is not adequately managed by other therapies. Not all patients respond to amantadine and it may have only a mild effect. However, it can cause a range of side effects including psychiatric effects e.g. hallucinations and insomnia (do not prescribe at night). Abrupt discontinuation should be avoided.