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Parkinson's disease - Management
How are oral and transdermal dopamine agonists used in seconday care?

  • Oral and transdermal dopamine agonists act directly on post-synaptic dopaminergic receptors, and do not need to be converted in the brain to active compounds.
  • When used as monotherapy in people with functionally-disabling early Parkinson's disease:
    • Dopamine agonists are slightly less effective than levodopa in terms of treating motor impairments and disability, but may delay motor complications.
    • However, treatment needs to be started slowly and carefully to avoid developing intolerable adverse effects. In particular:
      • Neuropsychiatric adverse effects (such as hallucinations, especially in older people, and impulse control disorders) may occur.
      • Drowsiness can be severe and may affect driving. In rare cases, sudden onset of sleep has occurred without awareness or warning signs; people should be informed of this.
      • Postural hypotension can occur, and is often worse at the start of treatment.
  • When used as an adjuvant to levodopa in later Parkinson's disease:
    • Dopamine agonists reduce off-time and levodopa dose, and improve motor impairments and activities of daily living.
    • This is at the expense of increased dopaminergic adverse effects that include dyskinesia, hallucinations, and postural hypotension.
  • The National Institute for Health and Clinical Excellence (NICE) recommends that, if a dopamine agonist is being considered, a non-ergot dopamine agonist (ropinirole, pramipexole, or rotigotine) should be used because of the association of fibrotic reactions, particularly cardiac fibrosis, with the use of ergot-derived dopamine agonists (bromocriptine, cabergoline, and pergolide; lisuride has been discontinued in the UK).
    • If an ergot-derived dopamine agonist (bromocriptine, cabergoline, or pergolide) is used (for instance, because a non-ergot dopamine agonist is ineffective or not tolerated), careful drug monitoring is required.
    • Rotigotine is only available as a patch for transdermal administration.

[American Medical Directors Association, 2002; CSM, 2002; CSM, 2003; National Collaborating Centre for Chronic Conditions, 2006; MHRA, 2007; MHRA, 2008]

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