Parkinsonism Treatments

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.
Cogentin 1mg/mL amps
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, 258mg 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 car
tridges
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 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*
Mirapex 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: 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. 3/2022)

This article originally appeared on MPR