POM: Prescription only medicine
This information is intended for use by health professionals
Treatment of Parkinson's diseaseIf treatment with a dopamine agonist is being considered, cabergoline is indicated as second line therapy in patients who are intolerant or fail treatment with a non-ergot compound, as monotherapy, or as adjunctive treatment to levodopa plus dopa-decarboxylase inhibitor, in the management of the signs and symptoms of Parkinson's disease. Treatment should be initiated under specialist supervision. The benefit of continued treatment should be regularly reassessed taking into account the risk of fibrotic reactions and valvulopathy (see sections 4.3, 4.4 & 4.8).
Adults and elderly patientsAs expected for dopamine agonists, dose response for both efficacy and side effects appears to be linked to individual sensitivity. Optimization of dose should be obtained through slow initial dose titration, from starting doses of 1 mg daily. The dosage of concurrent levodopa may be gradually decreased, while the dosage of cabergoline is increased, until the optimum balance is determined. In view of the long half-life of the compound, increments of the daily dose of 0.5-1 mg should be done at weekly (initial weeks) or bi-weekly intervals, up to optimal doses.The recommended therapeutic dosage is 2 to 3 mg/day for patients with signs and symptoms of Parkinson's disease. Cabergoline should be given as a single daily dose.
Paediatric populationThe safety and efficacy of cabergoline has not been investigated in children as Parkinson's disease does not affect this population.
General:As with other ergot derivatives, cabergoline should be given with caution to patients with severe cardiovascular disease, Raynaud's syndrome, peptic ulcer or gastrointestinal bleeding, or with a history of serious, particularly psychotic, mental disorders. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.The effects of alcohol on overall tolerability of cabergoline are currently unknown.
Hepatic Insufficiency:Lower doses of cabergoline should be considered in patients with severe hepatic insufficiency. Compared to normal volunteers and those with lesser degrees of hepatic insufficiency, an increase in AUC has been seen in patients with severe hepatic insufficiency (Child-Pugh Class C) who received a single 1 mg dose.
Postural Hypotension:Postural hypotension can occur following administration of cabergoline, particularly during the first days of administration of cabergoline. Care should be exercised when administering cabergoline concomitantly with other drugs known to lower blood pressure.
Fibrosis and Cardiac Valvulopathy and Possibly Related Clinical Phenomena:Fibrotic and serosal inflammatory disorders such as pleuritis, pleural effusion, pleural fibrosis, pulmonary fibrosis, pericarditis, pericardial effusion, cardiac valvulopathy involving one or more valves (aortic, mitral and tricuspid)or retroperitoneal fibrosis have occurred after prolonged usage of ergot derivatives with agonist activity at the serotonin 5HT2B receptor, such as cabergoline. In some cases, symptoms or manifestations of cardiac valvulopathy improved after discontinuation of cabergoline. Erythrocyte sedimentation rate (ESR) has been found to be abnormally increased in association with pleural effusion/fibrosis. Chest x-ray examination is recommended in cases of unexplained ESR increases to abnormal values. Serum creatinine measurements can also be used to help in the diagnosis of fibrotic disorder. Following diagnosis of pleural effusion/pulmonary fibrosis or valvulopathy, the discontinuance of cabergoline has been reported to result in improvement of signs and symptoms. (See section 4.3)Valvulopathy has been associated with cumulative doses, therefore patients should be treated with the lowest effective dose. At each visit, the risk benefit profile of cabergoline treatment for the patient should be reassessed to determine the suitability of continued treatment with cabergoline.Before initiating long-term treatment:All patients must undergo a cardiovascular evaluation, including echocardiogram, to assess the potential presence of asymptomatic valvular disease. It is also appropriate to perform baseline investigations of erythrocyte sedimentation rate or other inflammatory markers, lung function/chest x-ray and renal function prior to initiation of therapy. In patients with valvular regurgitation, it is not known whether cabergoline treatment might worsen the underlying disease. If fibrotic valvular disease is detected, the patient should not be treated with cabergoline (see section 4.3). During long-term treatment:Fibrotic disorders can have an insidious onset and patients should be regularly monitored for possible manifestations of progressive fibrosis. Therefore during treatment, attention should be paid to the signs and symptoms of:• Pleuro-pulmonary disease, such as dyspnoea, shortness of breath, persistent cough, or chest pain. • Renal insufficiency or ureteral/abdominal vascular obstruction that may occur with pain in the loin/flank, and lower limb oedema, as well as any possible abdominal masses or tenderness that may indicate retroperitoneal fibrosis. • Cardiac failure: cases of valvular and pericardial fibrosis have often manifested as cardiac failure. Therefore, valvular fibrosis (and constrictive pericarditis) should be excluded if such symptoms occur. Clinical diagnostic monitoring for development of fibrotic disorders, as appropriate, is essential. Following treatment initiation, the first echocardiogram must occur within 3-6 months, thereafter, the frequency of echocardiographic monitoring should be determined by appropriate individual clinical assessment with particular emphasis on the above-mentioned signs and symptoms, but must occur at least every 6 to 12 months.Cabergoline should be discontinued if an echocardiogram reveals new or worsened valvular regurgitation, valvular restriction, valve leaflet thickening or fibrotic valvular disease (see section 4.3). The need for other clinical monitoring (e.g. physical examination including, cardiac auscultation, X-ray, CT scan) should be determined on an individual basis. Additional appropriate investigations such as erythrocyte sedimentation rate, and serum creatinine measurements should be performed if necessary to support a diagnosis of a fibrotic disorder.
Somnolence/Sudden Sleep Onset:Cabergoline has been associated with somnolence and episodes of sudden sleep onset in patients with Parkinson's disease. Sudden onset of sleep during activities, in some cases without awareness or warning signs, has been reported. Patients must be informed of this and advised to exercise caution while driving or operating machines during treatment with cabergoline. Patients who have experienced somnolence and/or an episode of sudden sleep onset must refrain from driving or operating machines. A reduction of dosage or termination of therapy may be considered. (See section 4.7)
Impulse control disorders:Patients should be regularly monitored for the development of impulse control disorders. Patients and carers should be made aware that behavioural symptoms of impulse control disorders including pathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists including Cabaser. Dose reduction/tapered discontinuation should be considered if such symptoms develop.
|MedDRA System Organ Class||Frequency||Undesirable Effects|
|Cardiac disorders||Very Common||Valvulopathy (including regurgitation) and related disorders (pericarditis and pericardial effusion)|
|Respiratory, thoracic and mediastinal disorders||Common||Dyspnea|
|Uncommon||Pleural effusion, pulmonary fibrosis|
|Very rare||Fibrosis ( including pleural fibrosis)|
|Not Known||Respiratory disorder, respiratory failure, pleuritis, chest pain|
|Immune system disorders||Uncommon||Hypersensitivity reaction|
|Nervous system disorders||Common||Headache, somnolence, dizziness/vertigo, dyskinesia|
|Not Known||Sudden sleep onset, syncope, tremor|
|Eye disorders||Not Known||Visual impairment|
|Psychiatric disorders||Common||Hallucinations, sleep disturbances, increased libido, confusion|
|Uncommon||Delusions, psychotic disorder|
|Not Known||Aggression, hypersexuality, pathological gambling|
|Vascular disorders||Common||Cabergoline generally exerts a hypotensive effect in patients on long-term treatment; Postural hypotension|
|Not Known||Digital vasospasm|
|Gastrointestinal disorders||Very common||Nausea|
|Common||Constipation, dyspepsia, gastritis, vomiting|
|General disorders and administration site conditions||Very common||Peripheral oedema|
|Hepato-biliary disorders||Uncommon||Hepatic function abnormal|
|Skin and subcutaneous tissue disorders||Uncommon||Rash|
|Musculoskeletal and connective tissue disorders||Not Known||Leg cramps|
|Investigations||Common||Liver function tests abnormal, decreased haemoglobin, haematocrit, and/or red blood cell (>15% vs baseline)|
|Not Known||Blood creatinine phosphokinase increased|
* When concomitant use with levodopa therapy
Impulse control disordersPathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists including Cabaser (see section 4.4).
Reporting of suspected adverse reactionsReporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard.
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