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.


  1. 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.
  2. 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.
  3. 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 Cathy Whitlock

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. 

October 2014
Is Midlife Migraine Related to Late Life Parkinson’s Disease?

September 2014
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

August 2014
Everything You Need to Know About Medical Marijuana and Parkinson’s Disease

July 2014
The End for Levodopa Phobia: New Study Shows Sinemet is a Safe Initial Therapy for Treatment of Parkinson's Disease

June 2014
Is light therapy a potential treatment modality in Parkinson’s disease?

May 2014
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?

April 2014
An Update on DAT Scanning for Parkinson’s Disease Diagnosis

March 2014
Could Northera (Droxidopa) Be an Alternative Treatment for Low Blood Pressure and Passing Out Symptoms?

February 2014
The Dream of a Pill Free Existence and the Continuous Dopaminergic Pump for the Treatment of Parkinson's Disease

January 2014
Should I take Inosine to Raise my Uric Acid Levels and Treat my Parkinson’s Disease?

December 2013
Could Fungus and Mold be an Important Contributor to Parkinson’s Disease?

November 2013
Pimavanserin and the Hope for a Better Drug for Hallucinations and Psychosis in Parkinson’s Disease

October 2013
Halting of the Creatine Study

September 2013
The Importance of Identifying and Treating Caregiver Strain

August 2013
Putting Parkinson’s Disease Information into the Palm of Your Hand: Parkinson’s Enters the Smartphon

July 2013
What Parkinson’s Disease Patients Need to Know about H. Pylori Gastrointestinal Infections

June 2013
A2A Receptor Antagonists and Parkinson’s Disease Treatment

May 2013
Another Setback for Trophic Factor Treatment in Parkinson's Disease

April 2013
IPX066 and What Patients Really Want in New Carbidopa/Levodopa (Sinemet) Formulations

March 2013
The Weather Forecast for Parkinson’s Disease Calls for Worldwide Economic Storm

February 2013
Defeating the Barriers to Implementing Exercise Regimens in Parkinson’s Disease Patients

January 2013
When should you start medication therapy for Parkinson’s disease?

December 2012
Neurologist Care Reduces Hospitalizations in Parkinson's Disease

November 2012
A Victory in Court for Parkinson's Disease Patients who Require Ongoing Rehabilitative Therapies

October 2012
Given the recent FDA announcement about Mirapex (pramipexole), should I be worried about dopamine agonists?

September 2012
What about the new Parkinson’s Disease Vaccine? What should I know?

August 2012
Caffeine as a Potential Treatment for Parkinson’s Disease

July 2012
Time to Consider GPi DBS for Parkinson’s Disease: A Shift in the Practice of Patient Selection for DBS

June 2012
A New Treatment for Parkinson’s Disease-Related Constipation

May 2012
Too Many Pills: Improving Delivery Systems for Parkinson’s Disease Drugs

April 2012
Measuring Quality and Assessing Depression in Parkinson's Disease

March 2012
Watch out for Unexpected Obstacles if You Use a Cueing Strategy to Break Freezing of Gait in Parkinson’s Disease

February 2012
Pill Color, Generic Medications and Insurance Issues: Important Medication-Related Tips for the Parkinson’s Disease Patient

January 2012
Are Blood Tests for Parkinson’s Disease on the Horizon?

December 2011
Placing Stem Cells in Animal Models of Parkinson’s Disease: Another Important Step

November 2011
Important News for the Parkinson’s Disease Community: More Evidence that Sinemet and Madopar are Not Toxic and do Not Accelerate Disease Progression

October 2011
The Case for All Parkinson’s Disease Patients to be Co-managed by a Primary Care-Neurologist Team

September 2011
Scientists say Research on Brain Proteins Involved in Parkinson’s Disease is “Shaping” Up

August 2011
Who Actually Takes Care of Most of the Parkinson’s Patients Worldwide: The Need for Education and the Parkinson’s Toolkit

July 2011
If you are Dizzy or Passing Out, it could be Your Parkinson’s Disease or Parkinson’s Disease Medications

June 2011
How Will Group Visits for Parkinson’s Disease Fit into the Future of Parkinson’s Disease Care?

May 2011
Why Patients Should be Wary of Chelation Therapy for Parkinson’s Disease

April 2011
Opening the Door to Gene Therapy in Parkinson’s Disease: The Need for Refinement of the Technology and Approach

March 2011
Does it Matter if I Can’t Get Brand Sinemet?

February 2011
Should I get a DaTscan or PET scan to confirm my diagnosis of Parkinson’s disease?

January 2011
A Critical Reappraisal of the Worst Drugs in Parkinson’s Disease

December 2010
Environmental Risks for PD: Manganese, Welding, Mining, and Parkinsonism

November 2010
Calling for the FDA to Revise the Eight Sinemet a Day Rule

October 2010
Dry Cleaning Solvents and Potential Environmental Risks for Developing Parkinson’s Disease

September 2010
Maintaining the Balance: Why Parkinson’s Disease Patients Need to Understand Drug Recalls, Withdrawals, and Safety Alerts

August 2010
Shining a Light on Parkinson’s Disease: Optogenetics Has a Bright Future in Research

July 2010
Poor Medication Management of Parkinson's Disease During Hospital Admissions: Patients and Families Can Improve Their Hospital-Based Management

June 2010
Why Are Patches and Continuous Release Technology a Big Deal to Parkinson's?

May 2010
Is the PD SURG Trial Another Surge Forward for DBS Therapy?

April 2010
Cycling in PD in Those Who Can’t Walk: Is it Possible?

March 2010
New iPS Stem Cells for PD: What Does it Mean?

February 2010
Time for Comprehensive Care Networks for PD

January 2010
Is Parkinson's Disease a Prion Disease?

December 2009
Parkinson's Disease Linked to Gaucher's Disease

November 2009
Brain Cells Keep Time Stamps: Implications for Parkinson's Disease Therapies

October 2009
Is it Safe to Have an MRI with a DBS in Place?

September 2009
Take Care of Your Bones as They Are Affected in Parkinson's Disease (Even in Men)

August 2009
Is it Time to Start Paying Attention to Pain Symptoms in Parkinson's Disease Patients?

July 2009
Glutathione Fails to Demonstrate Significant Improvement in PD Symptoms

June 2009
Keeping an Eye on Trials Important to the Parkinson's Disease Patient

May 2009
Increased Risk of Melanoma in Parkinson's Disease

April 2009
Finally a DBS Expert Consensus Statement Aimed at Their True Customers: The Patients

March 2009
Pesticides and Environmental Exposure in Parkinson's disease: Should We Stay Away From the Stink Truck?

February 2009
Is Exercise Effective Treatment and Protection Against PD?

January 2009
Why are Transplant Trials Struggling to Succeed in the Treatment of PD?

December 2008
Are Monoamine Oxidase Inhibitors Disease Modifying or Neuroprotective in PD?

November 2008
Update on Gene Therapy for Parkinson's Disease

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Each month, we will feature a new column by NPF's National Medical Director, Dr. Michael Okun, on the latest developments in Parkinson's disease research. Read the latest "What's Hot in PD?" below.

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