Dopamine Receptor Agonists and Precursors
For a more detailed discussion of this topic, see Sympathomimetics and Dopamine Receptor Agonists, Sec. 31.29, p. 3241, in Comprehensive Textbook of Psychiatry, 9th Edition.
Dopamine agonists activate dopamine receptors in the absence of endogenous dopamine and have been widely used to treat idiopathic Parkinson’s disease, hyperprolactinemia, and certain pituitary tumors (prolactinoma). Because dopamine stimulates the heart and increases blood flow to the liver, kidneys, and other organs, low levels of dopamine are associated with low blood pressure and low cardiac input. Dopamine agonist drugs are also administered to treat shock and congestive heart failure.
Their use in psychiatry has been limited to treat such adverse effects of antipsychotic drugs as parkinsonism, extrapyramidal symptoms, akinesia, focal perioral tremors, hyperprolactinemia, galactorrhea, and neuroleptic malignant syndrome. The drugs in this class most commonly prescribed are bromocriptine (Parlodel), levodopa (also called L-Dopa; Larodopa), and carbidopa-levodopa (Sinemet). New dopamine receptor agonists include ropinirole (Requip), pramipexole (Mirapex), apomorphine (Apokyn), and pergolide (Permax). In 2007, pergolide was removed from the market because of the risk of serious damage to patients’ heart valves. Two New England Journal of Medicine studies confirmed the association of pergolide with increased chance of regurgitation (backflow of blood) of the mitral, tricuspid, and aortic valves of the heart.
More studies are underway to evaluate the effectiveness of dopamine receptor agonists in reversing the symptoms of selective serotonin reuptake inhibitor- (SSRI-) induced sexual dysfunction and post-SSRI sexual dysfunction. There are a few reports of amantadine’s (Symmetrel’s) role in augmenting antidepressant medications in patients with treatment-resistant depression and Cotard’s syndrome, a rare neuropsychiatric disorder in which a person holds a delusional belief that he or she is dead.
Pharmacologic Actions
L-Dopa is rapidly absorbed after oral administration, and peak plasma levels are reached after 30 to 120 minutes. The half-life of L-Dopa is 90 minutes. Absorption of L-Dopa can be significantly reduced by changes in gastric pH and by ingestion with meals. Bromocriptine and ropinirole are rapidly absorbed but undergo first-pass metabolism such that only about 30 to 55% of the dose is bioavailable. Peak concentrations are achieved 1.5 to 3 hours after oral administration. The half-life of ropinirole is 6 hours. Pramipexole is rapidly absorbed with little first-pass metabolism and reaches peak concentrations in 2 hours. Its half-life is 8 hours. Oral forms of apomorphine have been studied but are not available in the United States. Subcutaneous
apomorphine injection results in rapid and controlled systemic delivery, with linear pharmacokinetics over a dose ranging from 2 to 8 mg.
apomorphine injection results in rapid and controlled systemic delivery, with linear pharmacokinetics over a dose ranging from 2 to 8 mg.
After L-Dopa enters the dopaminergic neurons of the central nervous system (CNS), it is converted into the neurotransmitter dopamine. Apomorphine, bromocriptine, ropinirole, and pramipexole act directly on dopamine receptors. Dopamine, pramipexole, and ropinirole bind about 20 times more selectively to dopamine D3 than D2 receptors; the corresponding ratio for bromocriptine is less than 2:1. Apomorphine binds selectively to D1 and D2 receptors, with little affinity for D3 and D4 receptors. L-Dopa, pramipexole, and ropinirole have no significant activity at nondopaminergic receptors, but bromocriptine binds to serotonin 5-HT1 and 5-HT2 and α1-, α2-, and β-adrenergic receptors.
Therapeutic Indications
Medication-Induced Movement Disorders

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