Parkinsonism Treatments

PARKINSONISM TREATMENTS
Generic	Brand	Form	Strength	Adult Dose
ADENOSINE RECEPTOR ANTAGONIST
istradefylline	Nourianz	tabs	20mg, 40mg	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	—	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.
benztropine	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.
trihexy– phenidyl	—	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.
rivastigmine	Exelon	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.
bromocrip– tine	Parlodel	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.
prami– pexole*	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.
ropinirole*	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.
safinamide	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%.
selegiline	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. 2/2020)

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