August 2025
August 2025
| Starting dose | Titration | Maintenance dose range, usual | Dose adjustments¶ | Common side effects | |
| Levodopa* | |||||
| Carbidopa-levodopa IR | 25 mg/100 mg tablet: One-half tablet (12.5 mg/50 mg) orally 1 to 2 times daily | 25 mg/100 mg tablet: May increase by one-half tablet (12.5 mg/50 mg) per dose every 3 to 7 days, ultimately dosing 3 times daily spaced every 4 to 6 hours with meals | 300 to 600 mg levodopa per day in 3 divided doses at mealtimes | None required for kidney or hepatic dysfunction | Nausea, somnolence, dizziness, headache, constipation, orthostatic hypotension |
| Carbidopa-levodopa CR tablet, ER capsule | Not recommended for initial therapyΔ; can be used if carbidopa-levodopa IR is not tolerated due to nausea, somnolence, or dizziness | ||||
| Dopamine agonists* | |||||
| Pramipexole | IR: 0.125 mg orally 3 times daily | IR: May increase by 0.125 mg per dose every 5 to 7 days | 1.5 to 4.5 mg per day in 3 divided doses | Required for kidney function impairment | Nausea, somnolence, dizziness, headache, constipation, orthostatic hypotension, confusion, hallucinations, peripheral edema, impulse control disorders The rotigotine patch may also cause application site reaction |
| ER: 0.375 mg orally once daily at bedtime | ER: May increase by 0.375 mg per day every 5 to 7 days | 1.5 to 4.5 mg per day | Required for kidney function impairment; ER not recommended for CrCl <30 mL/min | ||
| Ropinirole | IR: 0.25 mg orally 3 times daily | IR: May increase by 0.25 mg per dose every 7 days to a total daily dose of 3 mg per day; thereafter, dose increases may occur in increments of 0.5 mg per dose every 7 days to a total daily dose of 9 mg per day, then in 1 mg per dose increments every 7 days for total daily doses >9 mg per day | 12 to 16 mg per day in 3 divided doses | Consider slower titration for CrCl <30 mL/min | |
| ER: 2 mg orally once daily at bedtime | ER: May increase by 2 mg per day at weekly or longer intervals | 12 to 16 mg per day | Consider slower titration for CrCl <30 mL/min | ||
| Rotigotine | Transdermal patch (2 mg/24 hours): Apply 1 patch once daily | May increase patch strength by 2 mg/24 hours every 7 days | 2 to 6 mg/24 hours | None required for kidney or mild to moderate hepatic dysfunction; has not been studied for use with severe hepatic impairment | |
| MAO B inhibitors* | |||||
| Rasagiline | 0.5 mg orally once daily | May increase to 1 mg once daily after 1 to 2 weeks | 0.5 to 1 mg per day | Required for hepatic impairment | Nausea, headache, confusion, hallucinations, falls, insomnia, dyskinesia |
| Safinamide | 50 mg orally once daily | May increase to 100 mg once daily after 14 days | 50 to 100 mg per day | Required for hepatic impairment | |
| Selegiline◊ | 5 mg orally once daily | May increase to 5 mg twice daily (with breakfast and lunch) after 1 to 2 weeks | 5 to 10 mg per day in 1 to 2 divided doses | Use with caution with kidney or hepatic impairment | |
| Others* | |||||
| Amantadine§ | IR: 100 mg orally once daily (avoid evening dosing) | May increase by 100 mg per day every 7 days to maximum of 400 mg per day in 2 to 3 divided doses | 200 to 300 mg per day in 2 to 3 divided doses | Required for CrCl ≤50 mL/min | Livedo reticularis, ankle edema, confusion, hallucinations, nightmares |
| ER capsule: 137 mg orally once daily at bedtime | May increase to 274 mg once daily after 7 days | 137 to 274 mg per day | Required for eGFR <60 mL/min/1.73 m2 | ||
| Trihexyphenidyl¥ | 1 mg orally twice daily | May increase by 1 to 2 mg per dose every 3 to 5 days as tolerated | 4 to 6 mg per day in 2 to 3 divided doses | Use with caution with kidney or hepatic impairment | Memory impairment, confusion, hallucinations, somnolence, dry mouth, blurred vision, constipation, nausea, urinary retention, impaired sweating, tachycardia |
CR: controlled-release; CrCl: creatinine clearance; eGFR: estimated glomerular filtration rate; ER: extended-release; IR: immediate-release; MAO B: monoamine oxidase B; PD: Parkinson disease.
* Dosing and titration are provided for use as initial therapy in patients with PD. Dosing and titration may differ for agents being used as adjunctive therapy and/or for management of advanced PD. When initiating or altering drug therapy, use of a drug interactions program is advised.
¶ Refer to drug monographs included within UpToDate for specific dose adjustment recommendations.
Δ For information on converting from immediate- to controlled- or extended-release formulations after initial titration, refer to the topic review and individual drug monographs included within UpToDate.
◊ Selegiline dosing is for the capsule and tablet formulations. An orally disintegrating tablet is approved as an adjunct to carbidopa-levodopa and is dosed differently.
§ Amantadine monotherapy is an alternative to early levodopa in younger patients who are at risk for dyskinesia, particularly when tremor is prominent.
¥ Anticholinergic drugs are very rarely used as monotherapy. They can sometimes be a useful addition to levodopa for young patients with prominent resting tremor or dystonia despite levodopa. They should be avoided in older adults with PD and those with significant cognitive impairment due to increased risk of adverse effects.
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