THERAPEUTICS

Brands

• Parlodel, Serocryptin, Cycloset

Generic?

• Yes

Class

• Antiparkinson agent, ergot

Commonly Prescribed for

(FDA approved in bold)

• Parkinson's disease (PD)

• Acromegaly

• Hyperprolactinemia

• Adjunct therapy for type 2 diabetes mellitus

How the Drug Works

• Dopamine agonist, with high affinity for the D2 receptor (less potent than pergolide or cabergoline). This action is the reason for effectiveness. Also has weak α agonist and 5-HT1A/1D agonist activity. In the treatment of hormone-secreting pituitary adenomas, bromocriptine works as a dopamine agonist, which inhibits prolactin-secreting cells in the anterior pituitary, reducing tumor size

• Bromocriptine alters neurotransmitter levels within hypothalamic circadian centers and affects glucose and lipid metabolism

How Long Until It Works

• PD: weeks

If It Works

• PD: may require dose adjustments over time or augmentation with other agents. Most PD patients will eventually require carbidopalevodopa to manage their symptoms

If It Doesn't Work

• PD: bradykinesia, gait, and tremor should improve. Non-motor symptoms including autonomic symptoms such as postural hypotension, depression, and bladder dysfunction do not improve. If the patient has significantly impaired functioning, add or replace with levodopa

Best Augmenting Combos for Partial Response or Treatment-Resistance

• For suboptimal effectiveness, add carbidopa-levodopa with or without a catechol-O-methyltransferase (COMT) inhibitor. Monoamine oxidase (MAO)-B inhibitor may also be beneficial

• For younger patients with bothersome tremor: anticholinergics may help

• For severe motor fluctuations and/or dyskinesias with good “on” time, functional neurosurgery (deep brain stimulation) is an option

• Depression is common in PD and may respond to low-dose SSRIs

• Cognitive impairment/dementia is common in mid- to late-stage PD and may improve with acetylcholinesterase inhibitors

• For patients with late-stage PD experiencing hallucinations or delusions, withdraw bromocriptine and consider oral atypical neuroleptics (quetiapine, olanzapine, clozapine). Acute psychosis is a medical emergency that may require hospitalization and low-dose haloperidol for stabilization

Tests

• None required