Pramipexole side effects and how to avoid them

Creator: SingleCare
Published: 2022-12-14T15:11:18-05:00

Pramipexole side effects include dyskinesia, sudden sleep attacks, and postural deformity

By SingleCare Team | Dec. 14, 2022 Medically reviewed by Josephine Bawab, Pharm.D.

Pramipexole is a generic prescription drug used to treat Parkinson’s disease or restless legs syndrome (RLS). Both conditions are associated with low dopamine, a chemical used by the brain to control muscle movements. For Parkinson’s disease, damage to the part of the brain that produces dopamine causes its levels to be too low. For RLS, healthcare professionals believe one part of the brain does not use dopamine the way it should. As a dopamine receptor agonist, pramipexole acts as dopamine in the brain, allowing people with Parkinson’s or RLS to achieve better muscle control and coordination. Pramipexole can be taken as immediate-release or extended-release tablets, sometimes prescribed as brand-name Mirapex ER. However,people with RLS usually take immediate-release pramipexole because doses are lower and usually taken once nightly. The side effects, drug interactions, and other issues are the same no matter what form of pramipexole is taken.

Common side effects of pramipexole for Parkinson’s disease

The most commonly experienced side effects of pramipexole will depend on the condition being treated and its severity. For people with early-stage Parkinson’s, the most common side effects are nausea, dizziness, and sleepiness. However, pramipexole side effects are more likely to occur in people with advanced Parkinson’s. For them, the most commonly experienced side effects are involuntary muscle movements, postural hypotension, and insomnia. In rough order, the most common side effects are:

Nausea
Dizziness
Sleepiness
Headache
Orthostatic or postural hypotension (sudden drop in blood pressure when sitting or standing up)
Muscle twitching and other involuntary muscle movements (dyskinesia and extrapyramidal symptoms)
Insomnia
Hallucinations
Fatigue
Weakness
Constipation
Abnormal dreams
Confusion
Dry mouth
Diarrhea
Memory problems
Frequent urination
Swelling of the hands, feet, ankles, and lower legs
Muscle spasms or twitching
Appetite loss
Upset stomach
Vomiting
Vision changes
Malaise
Stomach pain
Changes in gait
Muscle weakness
Muscle rigidity
Impotence

Common side effects of pramipexole for restless leg syndrome

For people taking pramipexole for RLS, the most common side effects are nausea and headache. As a general rule, however, people taking pramipexole for RLS experience far fewer side effects and are less likely to have problems compared to those who take it for Parkinson’s disease. The most common side effects when taking pramipexole for RLS are:

Headache
Nausea
Tiredness
Sleepiness
Constipation
Flu
Diarrhea
Dry mouth
Pain in the extremities
Stuffy nose

There are reports of people experiencing a worsening of their symptoms or augmentation (symptoms appearing earlier in the day) when taking pramipexole for RLS.

Serious side effects of pramipexole

The most serious side effects of pramipexole include:

Involuntary muscle movements
Falling asleep suddenly
Orthostatic hypotension
Fainting
Changes in mental status
Hallucinations
Psychosis
Changes in posture
Fibrosis of the abdominal cavity or lungs
Muscle pain
Compulsive behaviors
Unusual urges or loss of impulse control
Withdrawal symptoms resembling neuroleptic malignant syndrome (NMS)

Pramipexole and dyskinesia

Parkinson’s disease medications like levodopa or pramipexole can cause the uncontrollable jerks, twitches, and movements that many individuals associate with the disease. However, the incidence is related to the severity of the underlying condition. In clinical trials, almost half of people with advanced Parkinson’s experienced dyskinesias and another 28% experienced extrapyramidal symptoms, such as grimacing and other involuntary movements. Typically, dyskinesia is already a pronounced aspect in many Parkinson’s patients by the time the disease is advanced. For people with early-stage Parkinson’s, dyskinesia was not a significant side effect. Dyskinesia is also not a significant side effect in people taking pramipexole for RLS because the dosage is smaller. If involuntary movements start happening or get worse while taking pramipexole, inform the prescriber.

Pramipexole and sudden sleep attacks

In clinical trials, about 3% to 6% of people taking pramipexole for Parkinson’s disease fell asleep while engaged in normal daily activities, such as talking, eating, or working. Most of the time, falling asleep was preceded by drowsiness, but some people have reported falling asleep when completely alert and awake. Having sudden sleep attacks is considered a serious side effect because of the risk of accidents, falls, injury, or death. Anybody taking pramipexole who falls asleep without wanting to should inform the prescriber. The drug may need to be discontinued.

Pramipexole and postural deformity

Pramipexole treatment is associated with postural deformities in people with advanced Parkinson’s, most notably bent spine syndrome and Pisa syndrome. With bent spine syndrome, people are unable to stand straight, either bending forward at the hip or tilting sideways. With Pisa syndrome, the head faces down because the neck bends forward. These problems usually happen when starting pramipexole or increasing the dose. They typically improve when the dose is reduced or the drug is stopped altogether. Postural deformity is not life-threatening, but it can dramatically impair the quality of life. Talk to the prescriber if posture starts changing when taking pramipexole.

How soon do pramipexole side effects start?

Many of pramipexole’s side effects begin early in treatment, particularly the most common side effects, such as nausea, dizziness, headache, trouble sleeping, strange dreams, fatigue, dry mouth, and increased urination. Some of the mental and muscle problems are delayed side effects. These include hallucinations, memory impairment, sudden sleep onset, dyskinesia, and changes in muscle tone. Severe side effects are also delayed side effects. Neuroleptic malignant syndrome symptoms, however, occur soon after the drug is discontinued.

How long do pramipexole side effects last?

Some of the most common side effects of pramipexole may improve as the body adapts to the drug, but it’s not guaranteed. In some cases, doses may need to be reduced or the drug may need to be discontinued for improvement of certain adverse effects, such as drowsiness, postural deformities, and dyskinesia. Even if the drug is stopped, it doesn’t mean side effects will necessarily be gone. Most will improve, including dyskinesia, but healthcare professionals will usually prescribe levodopa or another dopamine agonist. Otherwise, the symptoms of Parkinson’s or RLS will return. These drugs may cause the same or similar side effects.

What are the long-term side effects of pramipexole?

Prolonged use of pramipexole or other dopamine agonists could result in dyskinesias. They could happen right away or take months or years to develop. It’s less likely when taking low doses of pramipexole for restless legs syndrome, but it still could happen if the drug is taken long enough.

Pramipexole contraindications

Pramipexole is contraindicated in any person who is allergic to the drug.

Pregnancy

Pramipexole has not been studied in pregnant women, but healthcare professionals do not believe there is a risk of it causing birth defects.

Breastfeeding

Healthcare professionals do not know if pramipexole is safe to take while breastfeeding. The drug is excreted into breast milk, but its effects on the nursing infant haven’t been studied. Theoretically, pramipexole can reduce milk production, but this hasn’t been proven.

Children

Pramipexole has not been approved by the FDA for use in anyone younger than 18 years of age.

Seniors

Pramipexole is used cautiously and with more careful monitoring in people 65 years of age and older. The drug is eliminated from the body by the kidneys, so it usually is eliminated slower in seniors, raising the risk of side effects. Neurological side effects, such as confusion, hallucinations, dizziness, lightheadedness, and dyskinesia, are also more likely to occur in people of advanced age.

Pramipexole warnings

Healthcare professionals use warnings and cautions when a drug may not be safe for some people. They may avoid the drug entirely, modify the dose, or monitor more closely for side effects.

Cautions

Pramipexole can worsen some existing medical conditions, so prescribers will need to monitor therapy more carefully. These pre-existing conditions include:

Heart disease: People with cardiac disease are more likely to experience orthostatic hypotension when taking pramipexole.

Kidney disease: The kidneys eliminate pramipexole from the body, so people with reduced kidney function are likely to experience more frequent and severe side effects of pramipexole.

Psychosis: People with schizophrenia or a history of psychosis are more likely to experience hallucinations and psychosis when taking pramipexole.

Sleep disorders: People who have problems sleeping and feel tired or drowsy during the day are more likely to experience sleep attacks when taking pramipexole.

Abuse and dependence

Drug abuse and physical dependence are not associated with pramipexole.

Withdrawal

The sudden discontinuation or a sudden dose reduction of pramipexole could cause a reaction similar to neuroleptic malignant syndrome (NMS). Symptoms include:

Confusion
Fever
Severe muscle stiffness
Depression
Anxiety
Insomnia
Fatigue
Sweating
Not caring (apathy)

When it’s time to stop pramipexole or switch to another medication, the prescribing healthcare provider will taper the pramipexole dose.

Overdose

Call a poison control center or get immediate medical attention if too much pramipexole is taken. The maximum dosage is 4.5 mg per day.

Pramipexole interactions

Some drugs interact with pramipexole, so healthcare professionals may avoid certain combinations, change dosages, or monitor for problems more carefully. These drugs include:

Depressants: Some of pramipexole’s side effects, such as sleepiness, dizziness, orthostatic hypotension, fainting, and falling asleep, are only going to be made worse when taken with drugs like opioids, sedatives, benzodiazepines, barbiturates, anxiety drugs, anticonvulsants, muscle relaxants, antihistamines, and alcohol.

Dopamine blockers: Dopamine blockers do the opposite of dopaminergic drugs like pramipexole, so they neutralize each other in terms of treatment benefits. Dopamine blockers include antipsychotics, some antidepressants, nausea treatments, sedatives, and GERD treatments, such as metoclopramide.

Drugs that block the body’s ability to eliminate pramipexole: Drugs that block the kidneys from filtering out pramipexole, such as cimetidine, will increase the risk of pramipexole side effects.

How to avoid pramipexole side effects

Avoiding adverse reactions may not always be possible, but there are ways to minimize them.

1. Tell the prescriber about pre-existing conditions

Start by giving the prescriber a complete picture of all pre-existing conditions, especially:

Low blood pressure
Difficulty controlling muscle movements
Sleep disorders or daytime sleepiness
Mental health issues, such as schizophrenia or psychosis
Kidney problems
Prescription drugs, over-the-counter medications, and dietary supplements being taken
Pregnancy or pregnancy plans
Breastfeeding or breastfeeding plans

2. Take pramipexole as directed

Follow all the instructions given by the prescriber when taking pramipexole. Above all, don’t take too much or take the drug too often. A missed dose can usually be taken when remembered, but not if it’s almost time for the next dose. If taking extended-release tablets, skip the missed dose if 12 hours have passed since it was supposed to be taken and take the next dose when scheduled. If questions arise about dosing, refer to the included drug information or seek medical advice from a trusted healthcare professional.

3. Avoid alcohol or other substances that cause sleepiness

The next rule is to avoid anything that causes sleepiness, especially alcohol, over-the-counter antihistamines, or similar drugs. Combining these with pramipexole not only increases any drowsiness or dizziness caused by pramipexole, but it also increases the risk of falling asleep unexpectedly.

4. Avoid driving or other risky activities

Be very careful about driving, operating machinery, or engaging in risky activities. It’s possible to fall asleep without meaning to when taking pramipexole. When feeling drowsy, stop what you’re doing, especially if you’re driving or doing anything else that could result in injury.

5. Take pramipexole with food

Take the tablet with a meal or snack to prevent nausea or similar side effects.

How to treat side effects of pramipexole

Sometimes side effects can’t be avoided. When they do happen, here’s what to do.

Drowsiness and dizziness

When feeling drowsy, dizzy, or faint, sit down. If driving, pull over when it’s safe. Ride it out and, when it passes, proceed with caution.

Falling asleep unexpectedly

Contact the prescriber if you fall asleep while engaged in normal daily activities. It doesn’t matter if falling asleep is preceded by sleepiness or attacks without warning.

Involuntary movements

Talk to the prescriber if any muscle twitching, jerking, shaking, or other involuntary movements start happening. Doses or your treatment may need to be modified.

Hallucinations and psychosis

Inform the prescriber about any hallucinations. The same applies to any other symptom of psychosis such as excessive suspicion, strange beliefs about the world, confusion, or scrambled thinking.

Changes in posture

Contact the prescriber if posture starts to change, particularly if you begin to stoop forward, tilt sideways, or your head starts drooping forward.

Out-of-control behaviors

Contact the prescriber if you begin losing control of impulses or start having bizarre urges, such as gambling too much, shopping too much, overeating, or acting on sexual urges.

Compulsive behaviors

Contact the prescriber if you or someone you’re caring for begins to engage in compulsive behaviors such as repeatedly pulling things apart and putting them together.