Pramipexole

MIRAPEX

What it isNon-ergot dopamine agonist with D3 preference; Parkinson disease and restless legs syndrome.

Why this oneAlmost entirely renally eliminated, it avoids CYP interactions but requires adjustment as kidney function falls.

What limits itAsk directly about impulse-control disorders and sudden sleep onset. Augmentation limits long-term use for restless legs.

FDA-approved for

FDA dosing	Population	Start	Target	Max
Parkinson's disease	Adults	0.125 mg TID	Titrate to effect	1.5 mg TID (4.5 mg/day)
Restless legs syndrome	Adults	0.125 mg QHS (2–3 h before bedtime)	0.25 mg QHS	0.5 mg QHS

Titration PD: increase no more often than every 5–7 days; RLS: every 4–7 days (14 days if CrCl 20–60)

Renal PD: CrCl 30–50 start 0.125 mg BID (max 0.75 mg TID); CrCl 15–30 start 0.125 mg QD (max 1.5 mg QD); <15 or HD: data not available

Hepatic Undefined

Falling asleep during activities of daily living / somnolence (sudden sleep onset)
Symptomatic orthostatic hypotension
Impulse-control / compulsive behaviors
Hallucinations and psychotic-like behavior
Dyskinesia
Postural deformity

Early PD: nausea, dizziness, somnolence, insomnia, constipation, asthenia, hallucinations
Advanced PD (with levodopa): orthostatic hypotension, dyskinesia, extrapyramidal syndrome
RLS: nausea, somnolence, fatigue, headache

Pregnancy No adequate human data; may cause fetal harm based on animal data

Lactation Undefined

NO BOXED WARNINGS

Principal riskImpulse-control disorders and sudden sleep onset

Cost, est. cash$10–$500/month

Generic entry2008

Therapeutic safety burden2 / 4

Overdose danger2 / 4

Weight-gain liability0 / 4

Sedation liability1 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk1 / 4

Legacy pregnancy categoryC

Defining liabilityOrthostasis, hallucinations, dyskinesia and impulse-control symptoms; abrupt withdrawal can be hazardous.

Box: minimal PK interactions