What is the recommended dose of Bromocriptine (Bromocriptine) for a patient with a condition such as Parkinson's disease, prolactinoma, or type 2 diabetes?

Bromocriptine Dosing Guidelines

Bromocriptine dosing varies dramatically by indication: for hyperprolactinemia/prolactinomas start with 1.25-2.5 mg daily and titrate to 2.5-15 mg daily; for Parkinson's disease start with 1.25 mg twice daily and titrate to 20-100 mg daily; for type 2 diabetes use the quick-release formulation at 0.8-4.8 mg daily; and for peripartum cardiomyopathy use 2.5 mg twice daily for 2 weeks followed by 2.5 mg daily for 4 weeks. 1, 2

Hyperprolactinemia and Prolactinomas

Initial Dosing and Titration

• Start with 1.25 mg at bedtime with food for the first 3 days to minimize side effects 1
• Increase by 1.25-2.5 mg every 2-7 days as tolerated until therapeutic response is achieved 1
• The therapeutic dosage range for adults is typically 2.5-15 mg daily 1
• For children aged 11-15 years, start with 0.5-2.5 mg daily and titrate to 2.5-10 mg daily as needed 1

Important Clinical Caveat

• Cabergoline is now preferred over bromocriptine for hyperprolactinemia due to superior efficacy (83% vs 59% prolactin normalization) and better tolerability (52% vs 72% adverse events) 2, 3
• Consider switching to cabergoline if bromocriptine is not well-tolerated or ineffective 2

Acromegaly

Dosing Protocol

• Start with 1.25-2.5 mg at bedtime with food for 3 days 1
• Add 1.25-2.5 mg every 3-7 days as tolerated 1
• The usual optimal therapeutic range is 20-30 mg daily, with a maximum of 100 mg daily 1
• Monitor growth hormone levels monthly and adjust dosage based on biochemical and clinical response 1

Parkinson's Disease

Starting and Maintenance Dosing

• Begin with 1.25 mg (half of a 2.5 mg tablet) twice daily with meals 1
• Increase by 2.5 mg daily every 14-28 days as tolerated 1
• Maintain concurrent levodopa dosing during titration if possible 1
• Typical effective doses range from 30-90 mg daily, though some patients require up to 100 mg daily 4, 5
• Safety has not been established for doses exceeding 100 mg daily 1

Clinical Evidence

• In severe Parkinson's disease (Stages 4-5), low-dose bromocriptine (mean 45-53 mg daily) produces satisfactory response, with improvement beginning within 48 hours 6
• When combined with levodopa, bromocriptine allows an average 41% reduction in levodopa dose 5
• Particularly beneficial for patients with levodopa-induced dyskinesias or "on-off" phenomena 5

Type 2 Diabetes Mellitus

Quick-Release Formulation Dosing

• Use the quick-release (QR) formulation specifically approved for diabetes 7, 8
• Doses range from 0.8-4.8 mg daily, administered in the early morning 7, 8
• This is substantially lower than doses used for Parkinson's disease and has not been associated with retroperitoneal fibrosis or cardiac valve abnormalities 7
• Reduces HbA1c by 0.4-1.2% as monotherapy or in combination with other antidiabetic agents 7, 8

Peripartum Cardiomyopathy (PPCM)

Specific Protocol for Severe Acute PPCM

• For women with LVEF <35%, use the "BOARD" protocol: 2.5 mg twice daily for 2 weeks, followed by 2.5 mg daily for 4 weeks 2
• This indication is supported by the American College of Cardiology and European Society of Cardiology 2
• Mandatory anticoagulation is required for all PPCM patients with low LVEF receiving bromocriptine due to reports of myocardial infarction 2
• Clinical trial data showed LVEF recovery from 27% to 58% at 6 months with bromocriptine versus 27% to 36% with standard therapy (P=0.012) 2

Special Populations and Precautions

Chronic Kidney Disease

• Bromocriptine should be used with caution in patients with CKD due to lack of safety studies 9, 2
• Only 2-6% of the drug appears in urine, as it is predominantly metabolized hepatically 9
• No specific dose adjustments are provided in guidelines, but careful monitoring is warranted 9

Pregnancy Considerations

• Discontinue bromocriptine as soon as pregnancy is confirmed unless treating rapidly expanding macroadenomas 10
• Use mechanical contraception during treatment until normal ovulatory cycles are restored 1
• If menstruation does not occur within 3 days of expected date, discontinue therapy and perform pregnancy test 1
• No evidence of increased abortion rates or congenital malformations in over 1,400 women exposed during early pregnancy 2

Common Side Effects and Monitoring

Dose-Related Adverse Effects

• Nausea and dizziness occur early (at 1-2 months) with lower doses (12-31 mg daily) 5
• Erythromelalgia occurs later (mean 10 months) with higher doses (mean 115 mg daily) 5
• Psychiatric disturbances occur at mean 6 months with mean dose of 66 mg daily 5

Dose-Independent Psychological Effects

• Mood changes, depression, aggression, hypersexuality, and impulse control disorders can occur at any dose and at any time during treatment 2, 10
• These effects are related to dopaminergic activity and require vigilant monitoring 2, 10

Cardiac Monitoring Requirements

• For doses >2 mg/week used in prolactinomas, obtain baseline echocardiogram and perform annual echocardiography 2, 10
• For doses ≤2 mg/week, echocardiographic surveillance can be reduced to every 5 years 2, 10
• Higher doses used in Parkinson's disease (up to 100 mg daily) carry increased risk but specific cardiac monitoring protocols are not well-defined in the evidence 1

Treatment Duration and Withdrawal

Long-Term Management

• For hyperprolactinemia, withdrawal can be attempted after 2+ years if prolactin normalizes and no visible tumor remains 10
• Most patients will experience recurrence and may require long-term or indefinite treatment 10
• Patients with macroadenomas require close monitoring with prolactin levels and imaging after withdrawal 10