Drug Information

Bromocriptine

Apo-Bromocriptine Aspen Bromocriptine Bagren Baimoting Barlolin Brameston Bromergon Bromo-Kin Bromocorn, Bromocriptin-Richter, Bromocriptina, Bromohexal, Butin, Cripsa, Demil, Deprolac, Kripton, Medocriptine, Parilac, Parlodel ,Pravidel, Protinal, Ronalin ,Serocryptin, Suplac, Umprel, Bromocriptine, Cycloset, SnapTabs ,Dom-Bromocriptine, PMS-Bromocriptine ,Anti-Parkinson's Agent, Dopamine Agonist,

Bromocriptine

Brand Names: U.S.

  • Cycloset®;
  • Parlodel®;
  • Parlodel® SnapTabs®
Brand Names: Canada

  • Apo-Bromocriptine®;
  • Dom-Bromocriptine;
  • PMS-Bromocriptine
Pharmacologic Category

  • Anti-Parkinson's Agent, Dopamine Agonist;
  • Antidiabetic Agent, Dopamine Agonist;
  • Ergot Derivative
Dosing: AdultAcromegaly: Oral: Initial: 1.25-2.5 mg daily increasing by 1.25-2.5 mg daily as necessary every 3-7 days; usual dose: 20-30 mg/day (maximum: 100 mg/day)

Hyperprolactinemia: Oral: Initial: 1.25-2.5 mg/day; may be increased by 2.5 mg/day as tolerated every 2-7 days until optimal response (range: 2.5-15 mg/day)

Parkinsonism: Oral: 1.25 mg twice daily, increased by 2.5 mg/day in 2- to 4-week intervals as needed (maximum: 100 mg/day)

Type 2 diabetes (Cycloset®): Oral: Initial: 0.8 mg once daily; may increase at weekly intervals in 0.8 mg increments as tolerated; usual dose: 1.6-4.8 mg/day (maximum: 4.8 mg/day)

Neuroleptic malignant syndrome (unlabeled use): Oral: 2.5 mg (orally or via gastric tube) every 8-12 hours, increased to a maximum of 45 mg/day, if needed; continue therapy until NMS is controlled, then taper slowly (Gortney, 2009; Strawn, 2007)

Dosing: PediatricHyperprolactinemia: Oral:

Children 11-15 years (based on limited information): Initial: 1.25-2.5 mg daily. Dosage may be increased as tolerated to achieve a therapeutic response (range 2.5-10 mg daily).

Children ≥16 years: Refer to adult dosing.

Dosing: GeriatricRefer to adult dosing.

Dosing: Hepatic ImpairmentNo guidelines are available; however, adjustment may be necessary due to extensive hepatic metabolism.

Dosage Forms: U.S.Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule, oral: 5 mg

Parlodel®: 5 mg

Tablet, oral: 2.5 mg

Cycloset®: 0.8 mg

Parlodel® SnapTabs®: 2.5 mg [scored]

Generic Equivalent Available: U.S.Yes: Excludes Cycloset®

AdministrationAdminister with food to decrease GI distress.

Cycloset®: Administer within 2 hours of waking in the morning.

UseTreatment of hyperprolactinemia associated with amenorrhea with or without galactorrhea, infertility, or hypogonadism; treatment of prolactin-secreting adenomas; treatment of acromegaly; treatment of Parkinson's disease

Cycloset®: Management of type 2 diabetes mellitus (noninsulin dependent, NIDDM) as an adjunct to diet and exercise

Use - Unlabeled/InvestigationalNeuroleptic malignant syndrome

Medication Safety Issues

Sound-alike/look-alike issues:

Bromocriptine may be confused with benztropine, brimonidine

Cycloset® may be confused with Glyset®

Parlodel® may be confused with pindolol, Provera®

Adverse Reactions SignificantNote: Frequency of adverse effects may vary by dose and/or indication.

>10%:

Central nervous system: Dizziness, fatigue, headache

Gastrointestinal: Constipation, nausea

Neuromuscular & skeletal: Weakness

Respiratory: Rhinitis

1% to 10%:

Cardiovascular: Hypotension (including postural/orthostatic), Raynaud's syndrome exacerbation, syncope

Central nervous system: Drowsiness, fatigue, lightheadedness, somnolence

Endocrine & metabolic: Hypoglycemia (4%; in combination with sulfonylureas or other antidiabetic agents: 7% to 9%)

Gastrointestinal: Abdominal cramps, anorexia, diarrhea, dyspepsia, GI bleeding, vomiting, xerostomia

Neuromuscular & skeletal: Digital vasospasm

Ocular: Amblyopia

Respiratory: Nasal congestion, sinusitis

Miscellaneous: Infection, flu-like syndrome

Frequency not defined, postmarketing, and/or case reports: Abdominal discomfort, alcohol potentiation, alopecia, anxiety, arrhythmia, ataxia, blepharospasm, blurred vision, bradycardia, cerebrospinal fluid rhinorrhea, cold tolerance decreased, confusion, constrictive pericarditis, delusional psychosis, depression, dyskinesia, dysphagia, dyspnea, ear tingling, epileptiform seizure, ergotism, erythromelalgia, facial pallor, faintness, hallucinations, heavy headedness, insomnia, involuntary movements, lassitude, lethargy, lightheadedness, mottling of skin, muscle cramps, nervousness, nightmares, “on-off” phenomenon, paranoia, paresthesia, pericardial effusion, peripheral edema, pleural effusion, pleural/pulmonary fibrosis, psychomotor agitation/excitation, rash, sleep requirement decreased, sluggishness, stroke, urinary frequency, urinary retention, vasovagal attack, ventricular tachycardia, vertigo, visual disturbance, weakness

Withdrawal reactions: Abrupt discontinuation has resulted in rare cases of a withdrawal reaction with symptoms similar to neuroleptic malignant syndrome.

Reported with dopamine agonists: Impulsive/compulsive behaviors (eg, pathological gambling, hypersexuality, binge eating)

ContraindicationsHypersensitivity to bromocriptine, ergot alkaloids, or any component of the formulation

Additional contraindications:

Parlodel®: Uncontrolled hypertension; pregnancy (risk to benefit evaluation must be performed in women who become pregnant during treatment for acromegaly, prolactinoma, or Parkinson's disease - hypertension during treatment should generally result in efforts to withdraw); postpartum women with a history of coronary artery disease or other severe cardiovascular conditions (unless withdrawal of medication is medically contraindicated)

Cycloset®: Syncopal migraine; breast-feeding

Warnings/PrecautionsConcerns related to adverse effects:

• Cardiac valvular fibrosis: Ergot alkaloids and derivatives have been associated with fibrotic valve thickening (eg, aortic, mitral, tricuspid); usually associated with long-term, chronic use.

• Cardiovascular effects: Symptomatic hypotension may occur in a significant number of patients. In addition, hypertension, seizures, MI, and stroke have been rarely associated with therapy. Severe headache or visual changes may precede events. The onset of reactions may be immediate or delayed (often may occur in the second week of therapy).

• Impulse control disorders: Dopamine agonists used for Parkinson’s disease or restless legs syndrome have been associated with compulsive behaviors and/or loss of impulse control, which has manifested as pathological gambling, libido increases (hypersexuality), and/or binge eating. Causality has not been established, and controversy exists as to whether this phenomenon is related to the underlying disease, prior behaviors/addictions and/or drug therapy. Dose reduction or discontinuation of therapy has been reported to reverse these behaviors in some, but not all cases.

• Melanoma: Risk for melanoma development is increased in Parkinson’s disease patients; drug causation or factors contributing to risk have not been established. Patients should be monitored closely and periodic skin examinations should be performed.

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• Pleural/retroperitoneal fibrosis: Rare cases of pleural and/or retroperitoneal fibrosis have been reported with prolonged daily use.

• Sedation: Sudden sleep onset and somnolence have been reported with use, primarily in patients with Parkinson’s disease. Patients must be cautioned about performing tasks which require mental alertness.

Disease-related concerns:

• Acromegaly: Appropriate use: In the treatment of acromegaly, discontinuation is recommended if tumor expansion occurs during therapy. Digital vasospasm (cold sensitive) may occur in some patients with acromegaly; may require dosage reduction.

• Cardiovascular disease: Use with caution in patients with cardiovascular disease (myocardial infarction, arrhythmia). Should not be used postpartum in women with coronary artery disease or other cardiovascular disease; use to control or prevent lactation or in patients with uncontrolled hypertension is not recommended.

• Dementia: Use with caution in patients with dementia.

• Diabetic ketoacidosis (DKA): Should not be used in patients with DKA due to lack of efficacy in this patient population.

• Hepatic impairment: Safety and efficacy have not been established in patients with hepatic impairment.

• Macroadenomas: Discontinuation of therapy in patients with macroadenomas has been associated with rapid regrowth of tumor and increased prolactin serum levels.

• Parkinson's disease: Safety has not been established for use >2 years in patients with Parkinson's disease.

• Peptic ulcer disease: Use with caution in patients with peptic ulcer disease.

• Psychosis: Use with extreme caution or avoid use in patients with psychosis.

• Renal disease: Safety and efficacy have not been established in patients with renal impairment.

• Type 1 diabetes mellitus: Should not be used in patients with type 1 diabetes mellitus (insulin dependent, IDDM) due to lack of efficacy in this patient population.

Concurrent drug therapy issues:

• Antidiabetic agents: There is limited efficacy of use in combination with thiazolidinediones or in combination with insulin. Combination therapy with other hypoglycemic agents may increase risk for hypoglycemic events; dose reduction of concomitant hypoglycemics may be warranted.

• Antihypertensives: Concurrent antihypertensives or drugs which may alter blood pressure should be used with caution.

• High potential for interactions: Use with caution in patients taking strong CYP3A4 inhibitors and/or major CYP3A4 substrates (includes protease inhibitors, azole antifungals, and some macrolide antibiotics); consider alternative agents that avoid or lessen the potential for CYP-mediated interactions.

• Levodopa: Concurrent use with levodopa has been associated with an increased risk of hallucinations; consider dosage reduction and/or discontinuation in patients with hallucinations. Hallucinations may require weeks to months before resolution.

Special populations:

• Pediatrics: Safety and effectiveness have not been established in children <11 years of age for pituitary adenoma.

• Pregnancy: Patients who receive during and immediately following pregnancy as a continuation of previous therapy (eg, acromegaly) should be closely monitored for cardiovascular effects.

Dosage form specific issues:

• Interchangeability (Cycloset®): Due to a difference in the formulation and resulting pharmacokinetics of Cycloset® ("quick-release" tablet) compared to other formulations of bromocriptine, interchangeability with any other bromocriptine product is not recommended in the setting of type 2 diabetes mellitus management.

Other warnings/precautions:

• Pituitary function evaluation: Complete evaluation of pituitary function should be completed prior to initiation of treatment of any hyperprolactinemia-associated dysfunction.

• Visual monitoring: Monitoring and careful evaluation of visual changes during the treatment of hyperprolactinemia is recommended to differentiate between tumor shrinkage and traction on the optic chiasm; rapidly progressing visual field loss requires neurosurgical consultation.

Metabolism/Transport EffectsSubstrate of CYP3A4 (major); Inhibits CYP1A2 (weak), 3A4 (weak)

Alpha-/Beta-Agonists: May enhance the adverse/toxic effect of Bromocriptine. Including increased blood pressure, ventricular arrhythmias, and seizure. Exceptions: Dipivefrin. Risk C: Monitor therapy

Antipsychotics (Atypical): May diminish the therapeutic effect of Anti-Parkinson's Agents (Dopamine Agonist). Risk D: Consider therapy modification

Antipsychotics (Typical): Anti-Parkinson's Agents (Dopamine Agonist) may diminish the therapeutic effect of Antipsychotics (Typical). Antipsychotics (Typical) may enhance the therapeutic effect of Anti-Parkinson's Agents (Dopamine Agonist). Management: Avoid concomitant therapy if possible and monitor for decreased effects of both agents when these combinations cannot be avoided. Atypical antipsychotics such as clozapine and quetiapine may be less likely to reduce the effects of anti-Parkinson's agents. Risk D: Consider therapy modification

Conivaptan: May increase the serum concentration of CYP3A4 Substrates. Risk X: Avoid combination

CycloSPORINE: Bromocriptine may increase the serum concentration of CycloSPORINE. Risk C: Monitor therapy

CycloSPORINE (Systemic): Bromocriptine may increase the serum concentration of CycloSPORINE (Systemic). Risk C: Monitor therapy

CYP3A4 Inhibitors (Moderate): May decrease the metabolism of CYP3A4 Substrates. Risk C: Monitor therapy

CYP3A4 Inhibitors (Strong): May decrease the metabolism of CYP3A4 Substrates. Risk D: Consider therapy modification

Dasatinib: May increase the serum concentration of CYP3A4 Substrates. Risk C: Monitor therapy

Efavirenz: May enhance the adverse/toxic effect of Ergot Derivatives. Specifically, the risk for peripheral vasospasm and ischemia may be increased. Risk X: Avoid combination

Itraconazole: May increase the serum concentration of Ergot Derivatives. Risk X: Avoid combination

Macrolide Antibiotics: May enhance the adverse/toxic effect of Ergot Derivatives. Specifically leading the development of ergotism. Exceptions: Azithromycin; Azithromycin (Systemic); Fidaxomicin (Systemic); Spiramycin. Risk D: Consider therapy modification

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MAO Inhibitors: May enhance the orthostatic hypotensive effect of Orthostatic Hypotension Producing Agents. Risk C: Monitor therapy

Methylphenidate: May enhance the adverse/toxic effect of Anti-Parkinson's Agents (Dopamine Agonist). Risk C: Monitor therapy

Metoclopramide: May diminish the therapeutic effect of Anti-Parkinson's Agents (Dopamine Agonist). Risk C: Monitor therapy

Nitroglycerin: Ergot Derivatives may diminish the vasodilatory effect of Nitroglycerin. This is of particular concern in patients being treated for angina. Nitroglycerin may increase the serum concentration of Ergot Derivatives. Risk X: Avoid combination

Posaconazole: May increase the serum concentration of Ergot Derivatives. Risk X: Avoid combination

Protease Inhibitors: May increase the serum concentration of Ergot Derivatives. Risk X: Avoid combination

Serotonin 5-HT1D Receptor Agonists: Ergot Derivatives may enhance the vasoconstricting effect of Serotonin 5-HT1D Receptor Agonists. Serotonin 5-HT1D Receptor Agonists may enhance the vasoconstricting effect of Ergot Derivatives. Risk X: Avoid combination

Serotonin Modulators: May enhance the adverse/toxic effect of other Serotonin Modulators. The development of serotonin syndrome may occur. Risk D: Consider therapy modification

Sibutramine: May enhance the serotonergic effect of Serotonin Modulators. This may cause serotonin syndrome. Risk X: Avoid combination

Sibutramine: May enhance the serotonergic effect of Ergot Derivatives. This may cause serotonin syndrome. Management: Sibutramine should generally be avoided in patients receiving treatment with ergot derivatives due to a theoretical risk of serotonin syndrome. If the combination cannot be avoided, monitor patients for signs/symptoms of serotonin toxicity. Risk D: Consider therapy modification

Tocilizumab: May decrease the serum concentration of CYP3A4 Substrates. Risk C: Monitor therapy

Voriconazole: May increase the serum concentration of Ergot Derivatives. Risk X: Avoid combination

Ethanol/Nutrition/Herb InteractionsEthanol: Avoid ethanol (may increase GI side effects or ethanol intolerance).

Herb/Nutraceutical: St John's wort may decrease bromocriptine levels.

Pregnancy Risk Factor

Drug ratings in pregnancy (US Food & Drug Administration)
Category Interpretation
A Controlled studies show no risk
Controlled studies in pregnant women fail to demonstrate a risk to the fetus in the first trimester with no evidence of risk in later trimesters. The possibility of fetal harm appears remote.
B No evidence of human risk in controlled studies
Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester and there is no evidence of a risk in later trimesters.
C Risk cannot be ruled out
Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal effects or other) and there are no controlled studies in women, or studies in women and animals are not available. Drugs should be given only if the potential benefits justify the potential risk to the fetus.
D Positive evidence of risk
There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (eg, if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective).
X Contraindicated in pregnancy
Studies in animals or human beings have demonstrated fetal abnormalities or there is evidence of fetal risk based on human experience, or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant.
Reproduced with permission from: Lacy CF, Armstrong LL, Goldman MP, Lance LL. Lexi-Comp Drug Information Handbook, 20th Edition. Hudson, OH: Lexi-Comp, 2011. Copyright © 2011.
Pregnancy ImplicationsNo evidence of teratogenicity or fetal toxicity in animal studies. Bromocriptine is used for ovulation induction in women with hyperprolactinemia. In general, therapy should be discontinued if pregnancy is confirmed unless needed for treatment of macroprolactinoma. Data collected from women taking bromocriptine during pregnancy suggest the incidence of birth defects is not increased with use. However, the majority of women discontinued use within 8 weeks of pregnancy. Women not seeking pregnancy should be advised to use appropriate contraception.

LactationEnters breast milk/contraindicated

Breast-Feeding ConsiderationsA previous indication for prevention of postpartum lactation was withdrawn voluntarily by the manufacturer following reports of serious adverse reactions, including stroke, MI, seizures, and severe hypertension. Use during breast-feeding is specifically contraindicated in the product labeling for Cycloset®. Use in postpartum women with a history of coronary artery disease or other severe cardiovascular conditions is specifically contraindicated in the product labeling for Parlodel® (unless withdrawal of medication is medically contraindicated). Based on the risk/benefit assessment, other treatments should be considered for lactation suppression.

Dietary ConsiderationsShould be taken with food to decrease GI distress.

Pricing: U.S. (www.drugstore.com)Capsules (Bromocriptine Mesylate)

5 mg (30): $135.99

Capsules (Parlodel)

5 mg (30): $259.99

Tablets (Parlodel)

2.5 mg (30): $165.99

Reference RangeRecommendations for glycemic control in adults with diabetes:

Hb A1c: <7%

Preprandial capillary plasma glucose: 70-130 mg/dL

Peak postprandial capillary blood glucose: <180 mg/dL

International Brand Names

  • Apo-Bromocriptine (NZ);
  • Aspen Bromocriptine (ZA);
  • Bagren (BR);
  • Baimoting (CL);
  • Barlolin (TW);
  • Brameston (BB, BM, BS, BZ, EC, GY, JM, PR, SR, TT);
  • Bromergon (HK, HR, TH);
  • Bromo-Kin (FR);
  • Bromocorn (PL);
  • Bromocriptin-Richter (HU);
  • Bromocriptina (CO);
  • Bromohexal (AU);
  • Butin (TW);
  • Cripsa (ID);
  • Demil (TW);
  • Deprolac (TW);
  • Kripton (AU);
  • Medocriptine (BG);
  • Parilac (IL);
  • Parlodel (AE, AR, AT, AU, BD, BE, BF, BH, BJ, BR, CH, CI, CY, CZ, DK, EE, EG, ES, ET, FI, FR, GB, GH, GM, GN, GR, HK, HN, HR, HU, IE, IN, IQ, IR, IT, JO, JP, KE, KP, KW, LB, LR, LY, MA, ML, MR, MT, MU, MW, MX, MY, NE, NG, NL, NO, NZ, OM, PE, PH, PK, PL, PT, PY, QA, RU, SA, SC, SD, SG, SK, SL, SN, SY, TH, TN, TR, TW, TZ, UG, UY, VE, YE, ZM, ZW);
  • Pravidel (DE, SE);
  • Protinal (IN);
  • Ronalin (AE, BH, CY, EG, IQ, IR, JO, KW, LB, LY, OM, QA, SA, SY, YE);
  • Serocryptin (AE, BH, CY, EG, HU, IQ, IR, IT, JO, KW, LB, LY, MY, OM, PE, QA, SA, SY, YE);
  • Suplac (TH);
  • Umprel (AT)
Mechanism of ActionSemisynthetic ergot alkaloid derivative and a dopamine receptor agonist which activates postsynaptic dopamine receptors in the tuberoinfundibular (inhibiting pituitary prolactin secretion) and nigrostriatal pathways (enhancing coordinated motor control).

In the treatment of type 2 diabetes mellitus, the mechanism of action is unknown; however, bromocriptine is believed to affect circadian rhythms which are mediated, in part, by dopaminergic activity, and are believed to play a role in obesity and insulin resistance. It is postulated that bromocriptine (when administered during the morning and released into the systemic circulation in a rapid, ‘pulse-like’ dose) may reset hypothalamic circadian activities which have been altered by obesity, thereby resulting in the reversal of insulin resistance and decreases in glucose production, without increasing serum insulin concentrations.

Pharmacodynamics/KineticsOnset of action: Parlodel®: Prolactin decreasing effect: 1-2 hours

Distribution: Vd: ~61L

Protein binding: 90% to 96% (primarily albumin)

Metabolism: Primarily hepatic via CYP3A; extensive first-pass biotransformation (Cycloset®: ~93%)

Bioavailability: Parlodel®: 28%; Cycloset®: 65% to 95%

Half-life elimination: Cycloset®: ~6 hours; Parlodel®: Biphasic: Terminal: 15 hours (range: 8-20 hours)

Time to peak, serum: Parlodel®: 1-3 hours; Cycloset®: 53 minutes

Excretion: Feces; urine (2% to 6% as unchanged drug and metabolites)

REFERENCES

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