What is the maximum dose of bromocriptine (dopamine agonist) for an adult patient with central fever and no significant medical history?

Maximum Dose of Bromocriptine for Central Fever

For central fever in adults with no significant medical history, bromocriptine can be safely escalated up to 30-40 mg per day in divided doses, though most patients respond to lower doses of 7.5-15 mg daily. 1, 2

FDA-Approved Dosing Framework

The FDA label for bromocriptine provides the foundational dosing structure, though central fever is an off-label indication 1:

• Initial dose: 2.5 mg daily with food 1
• Titration: Increase by 2.5 mg every 2-7 days as tolerated 1
• Maximum FDA-approved dose: 100 mg/day (for acromegaly and Parkinson's disease) 1

Evidence-Based Dosing for Central Fever

The typical effective dose range for central fever is 7.5-15 mg daily, with documented safe use up to 40 mg daily in refractory cases. 2, 3

Standard Dosing Protocol

• Median effective dose: 7.5 mg daily (range 2.5-40 mg) 3
• Duration of therapy: Median 13 days (range 5-160 days) 3
• Temperature response timeline: Significant decline occurs at 24 hours (-0.3°C), 48 hours (-0.5°C), and peaks at 72 hours (-0.7°C) 3

High-Dose Scenarios

When standard doses fail to control hyperthermia, escalation to 30-40 mg daily has been successfully used without significant adverse effects. 2, 4

• One case report documented successful control of refractory central hyperthermia with 30 mg daily after standard doses failed 2
• Another case achieved fever control with 40 mg daily 4
• High-dose bromocriptine (35-55 mg daily) has been safely used in Cushing's disease, establishing precedent for doses above 30 mg 5

Practical Titration Algorithm

Start low and titrate based on temperature response, not arbitrary dose limits:

1. Initiate: 2.5 mg twice daily (5 mg total) with food 1, 6
2. Assess response: Monitor core temperature every 4-6 hours 3
3. Titrate upward: Increase by 2.5-5 mg every 2-3 days if fever persists 1, 2
4. Target dose: 7.5-15 mg daily for most patients 3
5. Refractory cases: Continue escalation to 30-40 mg daily if needed 2, 4
6. Absolute maximum: 40 mg daily represents the highest documented safe dose for central fever 2

Critical Monitoring Parameters

• Temperature nadir: Expect maximum effect at 72 hours post-initiation 3
• Weaning attempts: Fever typically recurs with premature discontinuation 4
• Concurrent therapies: Account for confounding from antipyretics (reduces temperature by 0.1°C) and cooling devices (reduces by 0.2°C) 3

Important Caveats

Anticoagulation is mandatory in patients with low ejection fraction or peripartum cardiomyopathy receiving bromocriptine due to hypercoagulability risk. 7 However, this is not typically relevant for central fever patients unless they have concurrent cardiac pathology.

The dose-response relationship appears to exist, with higher doses providing better temperature control in refractory cases. 2 Do not assume failure at lower doses means the medication is ineffective—escalation is appropriate.

Bromocriptine should be continued for the duration of central hyperthermia, which may extend weeks to months depending on the underlying brain injury. 3, 6