You can find out more about NPF's National Medical Director, Dr. Michael S. Okun, by also visiting the NPF Center of Excellence, University of Florida Health Center for Movement Disorders and Neurorestoration. Dr. Okun is also the author of the Amazon #1 Parkinson's Best Seller 10 Secrets to a Happier Life.
More about this month's topic can be found in this article from The Wall Street Journal.
Impulse control disorders including behaviors such as gambling, shopping, pathological eating and hypersexuality can occur in 1 out of every 6 Parkinson’s disease patients taking a dopamine agonist drug. Since these drugs can in many cases be critical for optimization of care in Parkinson’s disease, it is important that we develop strategies for their safe use, and for their appropriate monitoring. In this month’s What’s Hot Column I address this issue, review recent adverse event data from the FDA, and share what has been learned from the National Parkinson Foundation’s Parkinson’s Outcomes Project. The hope is that all of this data can collectively inform better care.
Garcia-Ruiz and colleagues conducted a study using 2.7 million serious domestic and foreign adverse drug events reported to the FDA between 2003 and 2012. There were 710 events reported for dopamine receptor agonist drugs, and 870 for other dopamine receptor drugs. The agonist drugs were strongly associated with impulse control disorders. Two of the most common drugs used in Parkinson’s disease, pramipexole and ropinerole, had the strongest associations with impulse control disorders.
It is clear that the dopamine agonists are strongly associated with the occurrence of impulse control disorders. We decided to ask Peter Schmidt, PhD, who runs the NPF’s Parkinson’s Outcomes Project, if he had collected any data from NPF centers that could ultimately inform better Parkinson care. He shared with us the following figure:
Dr. Schmidt has determined the outcomes for Parkinson patients based on using a composite of six important research measures he collected across NPF centers – PDQ-39 (quality of life), TUG (walking), cognition (thinking), caregiver strain, falls, and hospitalization. Dr. Schmidt’s results inform us that more judicious use across the NPF Centers of Excellence of dopamine agonist drugs seems to be associated with better outcomes, but only to a certain point. Interesting is that the best centers who achieved the best outcomes were actually heavy users of dopamine agonists. He also taught us that some of the worst outcomes can be seen in the centers using the agonists the least.
It is now beyond doubt that dopamine agonists are associated with impulse control disorders. Data from the FDA and many other sources support this association. One important piece of information missing from recent studies is the notion that the dopamine agonist patch, Rotigotine, may have a lower incidence of impulse control issues and this is something that should be kept in mind. Both clinical experience and the NPF study support the idea that dopamine agonist use can be a powerful adjunct to the best Parkinson’s therapy, however clinicians prescribing dopamine agonists should inform patients and caregivers and should proactively monitor for behavioral disorders, just as I do in my clinic. Remember also that the patients suffering from impulse control issues may not have insight into the behavioral problems, and this lack of insight underscores the importance of involving caregivers in any proactive monitoring plan.
Finally, this is an example of the art versus the science of care. Based on the FDA analysis alone, if we had to make a rule about the use of dopamine agonists, that rule would be to simply use them sparingly. The right-hand side of Dr. Schmidt’s graph would strongly support that idea. However, a closer look at the left-hand side of the graph better informs us. It tells us that in the hands of a true expert, appropriate use of dopamine agonists can potentially shift patients from good care to great care. Dr. Schmidt and I have been working together to help people with Parkinson’s disease to understand the importance of expert care, and the dopamine agonist situation illustrates the importance and complexity of these issues. The best results don’t come from simple rules, they come from a personalized approach based on experience and evidence from our community of Parkinson’s disease patients.
- Garcia-Ruiz PJ, Martinez Castrillo JC, Alonso-Canovas A, Herranz Barcenas A, Vela L, Sanchez Alonso P, Mata M, Olmedilla Gonzalez N, Mahillo Fernandez I. Impulse control disorder in patients with Parkinson's disease under dopamine agonist therapy: a multicentre study. J Neurol Neurosurg Psychiatry. 2014 Aug;85(8):840-4. doi: 10.1136/jnnp-2013-306787. Epub 2014 Jan 16. PubMed PMID: 24434037.
- Garcia-Borreguero D, Kohnen R, Silber MH, Winkelman JW, Earley CJ, Högl B, Manconi M, Montplaisir J, Inoue Y, Allen RP. The long-term treatment of restless legs syndrome/Willis-Ekbom disease: evidence-based guidelines and clinical consensus best practice guidance: a report from the International Restless Legs Syndrome Study Group. Sleep Med. 2013 Jul;14(7):675-84. doi: 10.1016/j.sleep.2013.05.016. PubMed PMID: 23859128.
- Kaplan S, Tarsy D. Initial treatment of Parkinson's disease: an update. Curr Treat Options Neurol. 2013 Aug;15(4):377-84. doi: 10.1007/s11940-013-0236-7. PubMed PMID: 23645294.
Posted: 11/3/2014 12:56:22 PM by
Browse current and archived What's Hot in PD? articles, the National Parkinson Foundation's monthly blog for people with Parkinson's written by our National Medical Director, Dr. Michael S. Okun.
Is Midlife Migraine Related to Late Life Parkinson’s Disease?
Deep Brain Stimulation for Parkinson’s Disease: NPF Congratulates Mahlon DeLong and Alim-Louis Benabid and Looks to a Bright Future in Human Neural-Network Modulation
Everything You Need to Know About Medical Marijuana and Parkinson’s Disease
The End for Levodopa Phobia: New Study Shows Sinemet is a Safe Initial Therapy for Treatment of Parkinson's Disease
Is light therapy a potential treatment modality in Parkinson’s disease?
How does the most common genetic cause of Parkinson’s Disease (LRRK2) cause Parkinson’s disease and could it be used to help develop a better therapy?
An Update on DAT Scanning for Parkinson’s Disease Diagnosis
Could Northera (Droxidopa) Be an Alternative Treatment for Low Blood Pressure and Passing Out Symptoms?
The Dream of a Pill Free Existence and the Continuous Dopaminergic Pump for the Treatment of Parkinson's Disease
Should I take Inosine to Raise my Uric Acid Levels and Treat my Parkinson’s Disease?
Could Fungus and Mold be an Important Contributor to Parkinson’s Disease?
Pimavanserin and the Hope for a Better Drug for Hallucinations and Psychosis in Parkinson’s Disease
Halting of the Creatine Study
The Importance of Identifying and Treating Caregiver Strain
Putting Parkinson’s Disease Information into the Palm of Your Hand: Parkinson’s Enters the Smartphon
What Parkinson’s Disease Patients Need to Know about H. Pylori Gastrointestinal Infections
A2A Receptor Antagonists and Parkinson’s Disease Treatment
Another Setback for Trophic Factor Treatment in Parkinson's Disease
IPX066 and What Patients Really Want in New Carbidopa/Levodopa (Sinemet) Formulations
The Weather Forecast for Parkinson’s Disease Calls for Worldwide Economic Storm
Defeating the Barriers to Implementing Exercise Regimens in Parkinson’s Disease Patients
When should you start medication therapy for Parkinson’s disease?
Neurologist Care Reduces Hospitalizations in Parkinson's Disease
A Victory in Court for Parkinson's Disease Patients who Require Ongoing Rehabilitative Therapies
Given the recent FDA announcement about Mirapex (pramipexole), should I be worried about dopamine agonists?
What about the new Parkinson’s Disease Vaccine? What should I know?
Caffeine as a Potential Treatment for Parkinson’s Disease
Time to Consider GPi DBS for Parkinson’s Disease: A Shift in the Practice of Patient Selection for DBS
A New Treatment for Parkinson’s Disease-Related Constipation
Too Many Pills: Improving Delivery Systems for Parkinson’s Disease Drugs
Measuring Quality and Assessing Depression in Parkinson's Disease
Watch out for Unexpected Obstacles if You Use a Cueing Strategy to Break Freezing of Gait in Parkinson’s Disease
Pill Color, Generic Medications and Insurance Issues: Important Medication-Related Tips for the Parkinson’s Disease Patient
Are Blood Tests for Parkinson’s Disease on the Horizon?
Placing Stem Cells in Animal Models of Parkinson’s Disease: Another Important Step
Important News for the Parkinson’s Disease Community: More Evidence that Sinemet and Madopar are Not Toxic and do Not Accelerate Disease Progression
The Case for All Parkinson’s Disease Patients to be Co-managed by a Primary Care-Neurologist Team
Scientists say Research on Brain Proteins Involved in Parkinson’s Disease is “Shaping” Up
Who Actually Takes Care of Most of the Parkinson’s Patients Worldwide: The Need for Education and the Parkinson’s Toolkit
If you are Dizzy or Passing Out, it could be Your Parkinson’s Disease or Parkinson’s Disease Medications
How Will Group Visits for Parkinson’s Disease Fit into the Future of Parkinson’s Disease Care?
Why Patients Should be Wary of Chelation Therapy for Parkinson’s Disease
Opening the Door to Gene Therapy in Parkinson’s Disease: The Need for Refinement of the Technology and Approach
Does it Matter if I Can’t Get Brand Sinemet?
Should I get a DaTscan or PET scan to confirm my diagnosis of Parkinson’s disease?
A Critical Reappraisal of the Worst Drugs in Parkinson’s Disease
Environmental Risks for PD: Manganese, Welding, Mining, and Parkinsonism
Calling for the FDA to Revise the Eight Sinemet a Day Rule
Dry Cleaning Solvents and Potential Environmental Risks for Developing Parkinson’s Disease
Maintaining the Balance: Why Parkinson’s Disease Patients Need to Understand Drug Recalls, Withdrawals, and Safety Alerts
Shining a Light on Parkinson’s Disease: Optogenetics Has a Bright Future in Research
Poor Medication Management of Parkinson's Disease During Hospital Admissions: Patients and Families Can Improve Their Hospital-Based Management
Why Are Patches and Continuous Release Technology a Big Deal to Parkinson's?
Is the PD SURG Trial Another Surge Forward for DBS Therapy?
Cycling in PD in Those Who Can’t Walk: Is it Possible?
New iPS Stem Cells for PD: What Does it Mean?
Time for Comprehensive Care Networks for PD
Is Parkinson's Disease a Prion Disease?
Parkinson's Disease Linked to Gaucher's Disease
Brain Cells Keep Time Stamps: Implications for Parkinson's Disease Therapies
Is it Safe to Have an MRI with a DBS in Place?
Take Care of Your Bones as They Are Affected in Parkinson's Disease (Even in Men)
Is it Time to Start Paying Attention to Pain Symptoms in Parkinson's Disease Patients?
Glutathione Fails to Demonstrate Significant Improvement in PD Symptoms
Keeping an Eye on Trials Important to the Parkinson's Disease Patient
Increased Risk of Melanoma in Parkinson's Disease
Finally a DBS Expert Consensus Statement Aimed at Their True Customers: The Patients
Pesticides and Environmental Exposure in Parkinson's disease: Should We Stay Away From the Stink Truck?
Is Exercise Effective Treatment and Protection Against PD?
Why are Transplant Trials Struggling to Succeed in the Treatment of PD?
Are Monoamine Oxidase Inhibitors Disease Modifying or Neuroprotective in PD?
Update on Gene Therapy for Parkinson's Disease