Pramipexole (Mirapex)
Dopaminergic D3 agonist
- Bipolar depression2
- Unipolar depression3
- Treatment resistant depression1
- Inflammatory depression1
- Restless leg2
Features
Dosing
Start 0.125-0.25 qhs, raise by same amount every 5-7 days until 0.75 mg qhs. If tolerable, raise faster, to 1 mg after 5 days then 1.5 mg. Target 1-3 mg qhs, with higher doses needed for high levels of treatment resistance.
Treats RLS in lower doses (0.25-0.75). 10% of people are more activated on it and should take in morning.
Management
Explain it is the only treatment for depression that goes straight to the dopamine (D3) center that regulates reward, motivation, drive.
TOLERABILITY: Warn of sedation. Nausea, the most common side effect, can be treated with a proton pump inhibitor (lansoprazole, pantoprazole, esomeprazole, and rabeprazole). No weight gain, cognitive, or sexual side effects.
RISKS: hypotension (falls), edema, psychosis (usually hallucinations at high doses). Hedonic dysregulation, eg gambling, eating, shopping (3%).
Bipolar Depression
Start Pramipexole, Pramipexole has several randomized controlled trials demonstrating its efficacy in acute bipolar depression (Tundo A et al, Acta Psychiatr Scand 2019;140(2):116-125).
Off label use and risks, including hallucinations, gambling, fatigue, and edema reviewed with patient.
Major Depression
Start Pramipexole. Pramipexole is a dopaminergic that treated major depression and treatemnt-resistant depression in several randomized controlled trials (Tundo A et al, Life (Basel) 2023;13(4):1043).
Off label use and risks, including hallucinations, gambling, fatigue, and edema reviewed with patient.