Makindo Medical Notes

⚠️ 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

• BNF – Pramipexole
• NICE NG71: Parkinson’s disease in adults.

📝 Revisions

• September 2025 – Expanded with MOA, RLS dosing, cautions, and detailed side effects.