1. Dopamine receptor agonists
Domina Petric, MD

2. Dopamine receptor agonists
These drugs do not require enzymatic conversion to an active metabolite.
They have no potentially toxic metabolites.
They do not compete with other substances for active transport into the blood and across the blood-brain barrier.
Drugs selectively affecting certain dopamine receptors may have more limited adverse effects than levodopa.

3. Dopamine receptor agonists
Dopamine agonists have an important role as first-line therapy for Parkinson´s disease.
Their use is associated with a lower incidence of the response fluctuations and dyskinesias that occur with long-term levodopa therapy.
Dopaminergic therapy may be best initiated with a dopamine agonist.

4. Dopamine receptor agonists
The dose of the dopamine agonist is built up gradually depending on response and tolerance.
Dopamine agonists may be given to patients with parkinsonism who are taking levodopa and have end-of-dose akinesia, or on-off phenomenon, or are becoming resistant to treatment with levodopa.

5. Dopamine receptor agonists
The response to a dopamine agonist is generally disappointing in patients who have never responded to levodopa.

6. Bromocriptine Bromocriptine is D2 agonist.
It is now rarely used for parkinsonism.
The usual daily dose of bromocriptine for parkinsonism varies between 7,5 and 30 mg.
To minimize adverse effects, the dose is built up slowly over 2 or 3 months.

7. Pergolide Pergolide directly stimulates both D1 and D2 receptors.
It is not used for parkinsonism any more because its use has been associated with the development of valvular heart disease.

8. Pramipexole It is effective as monotherapy for mild parkinsonism.
It is also helpful in patients with advanced disease, permitting the dose of levodopa to be reduced and smoothing out response fluctuations.
Pramipexole may ameliorate affective symptoms.

9. Pramipexole
Possible neuroprotective effect: ability of pramipexole to scavenge hydrogen peroxide and enhance neurotrophic activity in mesencephalic dopaminergic cell cultures.
Pramipexole is rapidly absorbed after oral administration, reaching peak plasma concentrations in about 2 hours.
It is excreted largely unchanged in the urine.

10. Pramipexole Starting dose is 0,125 mg three times daily.
Dose is doubled after 1 week and again after another week.
Further increments in the daily dose are by 0,75 mg at weekly intervals.
Most patients require between 0,5 and 1,5 mg three times daily.

11. Pramipexole Renal insufficiency may necessitate dosage adjustment.
Extended-release preparation is taken once daily.
This preparation is more convenient for patients and avoids swings in blood levels of the drug over the day.

12. Ropinirole It is a relatively pure D2 receptor agonist.
It is effective as monotherapy in patients with mild disease.
It is also helpful in patients with more advanced disease using levodopa for smoothing the response fluctuations.
Start dose is 0,25 mg three times daily.
The total daily dose is increased by 0,75 mg at weekly intervals until the fourth week, after that increment is by 1,5 mg.

13. Ropinirole
In most cases dosage between 2 and 8 mg three times daily is necessary.
Ropinirole is metabolized by CYP1A2.
A prolonged-release preparation taken once daily is available.

14. Rotigotine
The dopamine agonist rotigotine is delivered daily through a skin patch: more continuous dopaminergic stimulation than oral medication in early disease.
Its efficacy in more advanced disease is less clear.

15. Dopamine receptor agonists
Adverse effects
Dopamine receptor agonists

16. Gastrointestinal effects
Anorexia, nausea and vomiting may occur when a dopamine agonist is introduced.
These side effects can be minimized by taking the medication with meals.
Constipation, dyspepsia and symptoms of reflux esophagitis may also occur.
Bleeding from peptic ulceration!

17. Cardiovascular effects
Postural hypotension may occur, particularly at the initiation of therapy.
Painless digital vasospasm is a dose-related complication of long-term treatment with the ergot derivatives (bromocriptine, pergolide).
Cardiac arrhythmias: indication for discontinuing treatment.
Peripheral edema.
Cardiac valvulopathy with pergolide.

18. Dyskinesias
Abnormal movements similar to those introduced by levodopa may occur and are reversed by reducing the total dose of dopaminergic drug being taken.

19. Mental disturbances
Confusion, hallucinations, delusions and other psychiatric reactions are more common and severe with dopamine receptor agonists than with levodopa.
Disorders of impulse control may lead to compulsive gambling, shopping, betting, sexual activity and other behaviors.
These behaviors clear on withdrawal of the offending medication.

20. Miscellaneous
Ergot-derived dopamine agonists (bromocriptine, pergolide): headache, nasal congestion, increased arousal, pulmonary infiltrates, pleural and retroperitoneal fibrosis, erythromelalgia.
Pergolide: cardiac valvulopathies.
Erythromelalgia consists of red, tender, painful, swollen feet and, occasionally, hands, at times associated with arthralgia.

22. Miscellaneous
In rare instances, an uncontrollable tendency to fall asleep at inappropriate times has occured, particularly in patients receiving pramipexole or ropinirole.

23. Contraindications
Dopamine agonists are contraindicated in patients with a history of psychotic illness or recent myocardial infarction, or with active peptic ulceration.
The ergot-derived agonists are best avoided in patients with peripheral vascular disease.

24. Apomorphine
Dopamine agonist

25. Apomorphine Apomorphine is a potent dopamine agonist.
Subcutaneous injection of apomorphine hydrochloride (Apokyn) is effective for the temporary relief (rescue) of off-periods of akinesia in patients on optimized dopaminergic therapy.
It is rapidly taken up in the blood and then the brain.

26. Apomorphine
Clinical benefit begins within 10 minutes of injection and persists for up to 2 hours.
The optimal dose is identified by administering increasing test doses until adequate benefit is achieved or a maximum of 10 mg is reached.
Most patients require a dose of 3-6 mg, but no more than three times daily!

27. Apomorphine
Nausea at the initiation of apomorphine treatment: pretreatment with the antiemetic trimethobenzamide (300 mg three times daily) for 3 days and then for at least 1 month after.
Other adverse effects: dyskinesias, drowsiness, chest pain, sweating, hypotension, bruising at the injection site.

28. Literature Katzung, Masters, Trevor. Basic and clinical pharmacology.