Alerts and Actions

April 2006

Compulsive behaviors – gambling – associated with selected Parkinson’s Disease therapies

Medicaton Safety Actions

1. Patients with Parkinson’s Disease should be advised to report changes in behavior or impulsive feelings after starting therapy.
2. Pharmacists should inspect the leaflets or computer printouts used in their practice to determine if this avoidable side effect is listed.  If not listed, it would be useful to verbally add this information during patient counseling – (Note: most drug information resources and patient information leaflets do not list this risk in their monographs – this is a “knowledge deficit” type of system-failure that can delay recognition and treatment).
3. Pharmacies should add this risk to the user-defined alert field in their dispensing software or ask their software vendor to add this alert.
4. Patients suspected of developing compulsive behaviors and feelings after starting therapy for Parkinson’s Disease should be referred to their physician.
5. Reports of compulsive behaviors should be documented in the patient’s medical and pharmacy profiles and the de-identified data submitted to the FDA using the MedWatch program at http://www.fda.gov/medwatch/index.html

Talking Points

Recent media reports have brought increased public attention to compulsive behaviors, an unusual but apparently rare complication of the use of certain dopamine agonists to treat Parkinson’s Disease.  Most interestingly, the behaviors include pathological gambling, shopping, increased libido and over-eating disorders.  In case reports dating back to 2000 and more recent reports in February 2006, investigators at Duke University and elsewhere have made tentative links to drugs such as ropinirole (Requip®), pramipexole (Mirapex®), pergolide (Permax®) and cabergoline (Dostinex®).  These drugs increase dopamine levels in the brain, offsetting the motor effects of Parkinson’s disease and investigators believe that selective stimulation of the D3 receptor may also increase the risk of compulsive behaviors in some patients.  Easy access to gambling may be a facilitating factor.  While compulsive behavior is not definitely linked to these therapies, there is increasing causal evidence.  The risk to any given patient appears very low yet the reports of financial and social harm to the patient are dramatic.  Limited information is available to clinicians and patients about this risk.  The behaviors appear to be reversible and if detected early, the pharmacist can play a key role in minimizing the financial and social harm to the patient.

References:         Arch Neurol 2006;63:298-300.

                          Arch Neurol. 2005;62:1377-1381.

                          Neurology. 2003;61:422-423.

                          Depress Anxiety. 2000;11:185-186.