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Dopamine Agonist (D2/D3 Receptor) Pregnancy: Avoid — animal studies show embryotoxicity; insufficient human data.

Pramipexole (Restless Legs Syndrome — Elderly)

Brand names: Mirapexin, Sifrol

Adult dose

Dose: RLS: 0.088 mg (88 mcg) once daily, 2–3 hours before bedtime; increase if needed by 0.088 mg every 4–7 days; maximum 0.54 mg (540 mcg) once daily. Parkinson's (if required): titrate from 0.088 mg TDS
Route: Oral
Frequency: Once daily (RLS); three times daily (Parkinson's)
Max: 0.54 mg/day (RLS); 3.3 mg/day (Parkinson's)
Pramipexole is first-line for moderate-severe RLS in elderly when non-pharmacological measures fail. RLS in elderly is associated with iron deficiency — check serum ferritin before starting (target >75 mcg/L; oral/IV iron if low). Augmentation (worsening and earlier onset of symptoms) occurs in 40–80% after long-term use — requires specialist review.

Paediatric dose

Route:
Not licensed in paediatrics.

Dose adjustments

Renal

Significant renal adjustment required: eGFR 20–50: start 0.088 mg once daily, max 0.54 mg once daily. eGFR <20: 0.088 mg every other day, max 0.18 mg every other day.

Hepatic

No dose adjustment required for hepatic impairment.

Clinical pearls

  • Augmentation is the major long-term clinical problem with dopamine agonists in RLS: symptoms spread to arms, occur earlier in the day, and become more intense — occurs in 40–80% after long-term use. Management: reduce dose gradually, switch to alpha-2-delta calcium channel ligand (gabapentin enacarbil, pregabalin) or low-dose opioid (oxycodone)
  • Impulse control disorder (ICD) warning: MHRA 2012 — all patients must be informed of ICD risk before starting. Screening question at every review: 'Have you been gambling more than usual, or had unusual urges?' Dose reduction or switch to non-dopaminergic treatment if ICDs develop
  • Iron treatment first: RLS guidelines (IRLSSG 2023) — measure serum ferritin in ALL RLS patients; if ferritin <75 mcg/L, treat with iron (oral ferrous sulfate or IV ferric carboxymaltose if oral not tolerated) before adding pramipexole — iron supplementation alone may resolve symptoms in iron-deficient elderly

Contraindications

  • Hypersensitivity to pramipexole
  • Augmentation without appropriate review (continue at risk of further worsening)

Side effects

  • Nausea (especially on initiation — take with food)
  • Somnolence (sudden sleep onset — MHRA warning: do NOT drive until known not to affect alertness)
  • Impulse control disorders (ICD): pathological gambling, hypersexuality, binge eating, compulsive shopping — up to 15%; MHRA 2012 warning; dose-dependent
  • Augmentation of RLS (40–80% after 2–5 years — symptoms worsen, spread, occur earlier in day)
  • Orthostatic hypotension (significant fall risk in elderly)
  • Hallucinations (especially with Parkinson's dose)
  • Peripheral oedema

Interactions

  • Dopamine antagonists (antipsychotics, metoclopramide, domperidone — pharmacodynamic antagonism; reduce efficacy)
  • Cimetidine (reduces renal excretion — increased pramipexole levels; reduce dose)
  • Alcohol (additive CNS depression and hypotension)

Monitoring

  • Sleepiness and ability to drive (MHRA warning — sudden onset sleep)
  • Impulse control behaviours (at every clinic review)
  • RLS symptom diary (frequency, severity, time of onset — augmentation detection)
  • Serum ferritin (iron stores — treat if <75 mcg/L)
  • Blood pressure (orthostatic hypotension — fall risk in elderly)
  • Renal function (dose adjustment criterion)

Reference: BNFc; BNF 90; MHRA Drug Safety Update 2012 (impulse control disorders); IRLSSG Diagnostic Criteria and Treatment Recommendations 2023; Allen et al. Sleep Medicine Reviews (augmentation); NICE CG35 (Parkinson's disease). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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