Parkinsonism Treatments
PARKINSONISM TREATMENTS
Generic Brand Form Strength Adult Dose
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.
safinimide 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. 8/2019)

This article originally appeared on MPR