Pramipexole (Mirapexin) 💊
⚠️ Safety note: Treatment with dopamine-receptor agonists, including pramipexole, is associated with impulse control disorders (pathological gambling, binge eating, hypersexuality).
Patients and their carers should be counselled about these risks and monitored regularly.
📘 About
- Always check the BNF for latest prescribing advice.
- Pramipexole is a non-ergot dopamine receptor agonist, used in Parkinson’s disease (PD) and restless legs syndrome (RLS).
- May be given as monotherapy in early PD or combined with levodopa in advanced disease to smooth out motor fluctuations and reduce “off” periods.
⚙️ Mode of Action
- Highly selective D2/D3 dopamine receptor agonist.
- Stimulates dopamine receptors in the striatum → improves motor symptoms in PD.
- In RLS, thought to modulate central dopaminergic pathways regulating movement and sleep.
💊 Indications & Example Doses
- Parkinson’s disease (with or without levodopa):
- Week 1: 88 micrograms TDS.
- Week 2: 180 micrograms TDS.
- Week 3: 350 micrograms TDS.
- Week 4: 700 micrograms TDS.
- Titrate gradually according to response and tolerability.
- Maximum daily dose: 3.3 mg/day in divided doses.
- Levodopa dose may need to be reduced as pramipexole is uptitrated to minimise dyskinesia.
- Moderate to severe restless legs syndrome (RLS):
- Specialist initiation – lower doses than in PD.
- Typical: 88 micrograms once daily, 2–3 hours before bedtime. May be increased gradually to 540 micrograms daily.
🔄 Interactions
- See BNF for complete list.
- Additive CNS depression with alcohol or sedatives.
- Caution with other dopamine agonists or antagonists (e.g., antipsychotics may reduce effect).
⚠️ Cautions
- Do not stop abruptly – risk of neuroleptic malignant syndrome (NMS)-like reaction.
- Reduce dose in renal impairment (renally excreted).
- Risk of sudden sleep onset – counsel about driving and machinery use.
- Monitor for impulse control disorders and hallucinations (especially in elderly).
🚫 Contraindications
- See BNF – hypersensitivity to pramipexole or excipients.
- Caution in severe psychiatric disorders (risk of worsening hallucinations/psychosis).
💥 Side Effects
- Neuropsychiatric: Impulse control disorders, hallucinations, confusion, insomnia.
- Neurological: Excessive daytime sleepiness, sudden onset of sleep, dizziness.
- Cardiovascular: Postural hypotension, hypotensive reactions.
- GI: Nausea, constipation.
- Others: Peripheral oedema, fatigue.
📖 References
📝 Revisions
- September 2025 – Expanded with MOA, RLS dosing, cautions, and detailed side effects.
