Management of Non-Motor Symptoms in Parkinson's Disease: Pramipexole Versus Rotigotine

Abstract

Introduction: Non-motor symptoms (NMS) (apathy, depression, restless legs, pain, sleep disturbance) dominate Parkinson's disease (PD) disability. Dopamine agonists (pramipexole, rotigotine) may address NMS better than levodopa. Methods: Systematic review of 7 RCTs (n=1,867) comparing pramipexole (1.5–4.5 mg/day) versus rotigotine patch (2–8 mg/24h) versus levodopa. Inclusion: PD with NMSS (Non-Motor Symptoms Scale) score ≥40. Primary outcome: NMSS change at 6 months. Secondary: MADRS (depression), PDSS-2 (sleep), UPDRS part III (motor). Results: Rotigotine improved NMSS by –21.4 points (pramipexole –18.2, levodopa –8.9, p<0.001 for both vs levodopa). Rotigotine was superior for sleep (PDSS-2 –8.5 vs –4.1) and pain. Pramipexole was superior for depression (MADRS –6.2 vs –3.4). Impulse control disorders occurred in 11% (pramipexole) vs 5% (rotigotine). Discussion: Patch formulation provides continuous dopaminergic stimulation, beneficial for nocturnal symptoms. However, transdermal irritation occurs in 12%. Conclusion: Rotigotine is preferred for PD patients with prominent sleep and pain symptoms; pramipexole for depression.