What is the recommended dosage and usage of Bromocryptine (Bromocriptine) for treating Parkinson's disease and hyperprolactinemia?

Bromocriptine Dosing and Clinical Use

Hyperprolactinemia and Prolactinomas

For hyperprolactinemia, start bromocriptine at 1.25-2.5 mg daily with food, titrating by 2.5 mg every 2-7 days to a therapeutic range of 2.5-15 mg/day in adults, though cabergoline is now the preferred dopamine agonist due to superior efficacy (83% vs 59% prolactin normalization) and better tolerability (52% vs 72% adverse events). 1, 2

Initial Dosing Strategy

• Begin with 1.25-2.5 mg once daily with food at bedtime to minimize side effects 2
• Increase by 2.5 mg every 2-7 days as tolerated until optimal response is achieved 2
• Therapeutic dosage typically ranges from 2.5-15 mg daily in adults 2

Pediatric Considerations (Ages 11-15)

• Start with 1.25-2.5 mg daily 2
• Therapeutic range is 2.5-10 mg daily for prolactin-secreting adenomas 2

Monitoring Requirements

• Obtain baseline echocardiogram before initiating therapy 3
• For doses >2 mg/week: annual echocardiography with cardiac auscultation 4, 3
• For doses ≤2 mg/week: echocardiographic surveillance every 5 years 4, 3

Treatment Discontinuation

• Consider gradual dose reduction after prolactin normalization for at least 2 years with no visible residual tumor on MRI 4, 3
• Withdrawal typically results in return of hyperprolactinemia in most patients 5

Parkinson's Disease

For Parkinson's disease, initiate bromocriptine at 1.25 mg twice daily with meals, increasing by 2.5 mg every 14-28 days to achieve optimal response while maintaining concurrent levodopa therapy, with typical effective doses ranging from 5-100 mg/day. 2, 6

Dosing Protocol

• Start with 1.25 mg (½ of 2.5 mg tablet) twice daily with meals 2
• Assess every 2 weeks during titration 2
• Increase by 2.5 mg every 14-28 days as needed 2
• Maximum dosage should not exceed 100 mg/day 2

Combination Therapy Strategy

• Maintain levodopa dosage during bromocriptine introduction if possible 2
• Bromocriptine combined with levodopa is more effective than bromocriptine alone (71% improvement vs 58-62% with monotherapy) 6
• If levodopa reduction is needed due to adverse effects, decrease gradually while increasing bromocriptine in small 2.5 mg increments 2

Efficacy by Dose Range

• Low dose (5-30 mg/day): 58% improvement as monotherapy in mild-moderate disease; 71% improvement when combined with levodopa 6
• High dose (31-100 mg/day): 62% improvement as monotherapy; 58% improvement with levodopa in advanced disease 6
• Bromocriptine does not induce "on-off" fluctuations when used as monotherapy 6

Acromegaly

For acromegaly, start bromocriptine at 1.25-2.5 mg at bedtime with food for 3 days, then increase by 1.25-2.5 mg every 3-7 days until optimal benefit is achieved, with usual therapeutic doses of 20-30 mg/day (maximum 100 mg/day). 2

Titration Schedule

• Initial dose: 1.25-2.5 mg at bedtime with food for 3 days 2
• Add 1.25-2.5 mg every 3-7 days as tolerated 2
• Usual optimal range: 20-30 mg/day 2
• Maximum: 100 mg/day 2

Monitoring and Assessment

• Re-evaluate monthly and adjust based on growth hormone reductions or clinical response 2
• Periodic assessment of circulating growth hormone levels guides therapeutic potential 2
• If no significant growth hormone reduction occurs after brief trial, reassess clinical features and consider dosage adjustment or discontinuation 2

Special Consideration for Irradiated Patients

• Withdraw bromocriptine yearly for 4-8 weeks to assess radiation effects and continued need for therapy 2
• Recurrence of symptoms or growth hormone increases indicates active disease requiring continued treatment 2

Side Effects and Management

Common Adverse Effects

• Gastrointestinal intolerance, postural hypotension, and psychological effects (mood changes, depression, aggression, hypersexuality, impulse control disorders) are common 3
• Small nocturnal dose increments reduce gastrointestinal intolerance and postural hypotension 1
• Psychological side effects are dose-independent and may be more common in children and adolescents 1

Critical Safety Concerns

• Cardiac valvulopathy risk: Higher doses used in Parkinson's disease (up to 100 mg/day) carry increased risk compared to prolactinoma doses 1, 3
• CSF leak: Tumor shrinkage in prolactinomas invading sphenoid bone can cause rhinorrhea requiring urgent intervention 1
• Long-term use has minimal harmful effects on renal, hepatic, cardiac, or hematologic functions at therapeutic doses 7, 8

Important Clinical Caveats

When to Consider Alternatives

• Cabergoline is now preferred over bromocriptine for hyperprolactinemia due to superior efficacy and tolerability 1, 3
• Consider surgery if vision deteriorates or fails to improve on medical therapy 1, 3
• Dopamine agonist resistance is defined as failure to normalize prolactin or achieve <50% tumor reduction after 3-6 months at maximally tolerated doses (at least 2 mg/week) 1

Pregnancy Considerations

• Use mechanical contraception until normal ovulatory cycles are restored 2
• Discontinue bromocriptine if menstruation is 3 days late and perform pregnancy test 2
• No evidence of increased abortion rates or congenital malformations in >1400 women exposed during early pregnancy 3

General Principles

• Always administer with food to improve tolerability 2
• Evaluate frequently during dose escalation to determine lowest effective dose 2
• Most beneficial effects reverse upon withdrawal 5