(FDA approved in bold)

• Parkinson’s disease (PD)
  
• Restless legs syndrome (RLS)
  
• Fibromyalgia

• Dopamine agonist, with high affinity for the D2 receptor. This action is likely the main reason for effectiveness in PD. Also binds with high affinity to D3 receptors, but the importance of this is unclear. The mechanism of action for RLS is probably related to D2 receptor agonism

• PD – weeks
  
• RLS – days to weeks

• PD – may require dose adjustments over time or augmentation with other agents. Most PD patients will eventually require carbidopa-levodopa to manage their symptoms
  
• RLS – safe for long-term use with dose adjustments

• 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 carbidopa-levodopa with or without pramipexole
  
• RLS – Rule out peripheral neuropathy, iron deficiency, thyroid disease. Change to another drug such as a benzodiazepine. Antiepileptic drugs (AEDs) such as gabapentin or carbamazepine may also be beneficial. In severe cases consider opioids

• For suboptimal effectives add carbidopa-levodopa with or without a COMT inhibitor. MAO-B inhibitors 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 is an option. Adding pramipexole may allow reduction of total levodopa dose which can help dyskinesias
  
• Depression is common in PD and may respond to SSRIs
  
• Cognitive impairment/dementia is common in mid-late stage PD and may improve with acetylcholinesterase inhibitors
  
• For patients with late-stage PD experiencing hallucinations or delusions, withdraw pramipexole and consider oral atypical neuroleptics (quetiapine, olanzapine, clozapine). Acute psychosis is a medical emergency that may require hospitalization
  
• For RLS, can change to a different dopamine agonist or add another drug such as a benzodiazepine. AEDs such as gabapentin or carbamazepine may be beneficial. In severe cases consider opioids

• None required