Report of Cases (from
Frequency of New-Onset Pathologic Compulsive Gambling or Hypersexuality After Drug Treatment of Idiopathic Parkinson Disease )
Case 1.
After 3 years of parkinsonism, a 46-year-old married man was diagnosed as having PD, and ropinirole monotherapy was initiated, with the dosage gradually increased to 15 mg/d. He subsequently developed “excessive libido” that “occasionally causes arguments with my wife.” Later carbidopa/levodopa was added, and the hypersexuality persisted for the next 2 years, with the patient or wife mentioning this to physicians at least 2 other times. Ultimately, with the hypersexuality “becoming a marital issue,” the dose of ropinirole was tapered and replaced with entacapone, leading to reduction of problematic libido.
Case 2.
A 52-year-old married man with an 11-year history of levodopa-responsive PD developed a compulsive gambling habit 5 months after starting pramipexole therapy and 2 months after reaching the maintenance dose of 4.5 mg/d. He had previously gambled at casinos in Las Vegas, NV, only once or twice a year; he never had trouble stopping and never lost large sums of money. Now, he gambled daily, “sometimes [for] 36 hours straight,” sometimes awakening in the middle of the night and driving to the casino. His wife commented that this activity was “completely out of character for him.” His losses totaled $15,000. He also engaged in compulsive lawn care activities, consisting of blowing leaves for up to 6 hours at a time, finding it difficult to stop. Within weeks of stopping pramipexole therapy, the compulsion to gamble abated completely.
Case 3.
A 68-year-old man was admitted to the psychiatry department after gambling more than $200,000 in a 6-month period. His family also noted “hypersexuality,” and he harbored the delusion that his ex-wife was a prostitute. His only medications were pramipexole, 4.5 mg/d, and levodopa, 600 mg/d (as carbidopa/levodopa), initially administered when PD was diagnosed 3 years earlier. His daughter said that he had formerly been financially meticulous, never going to casinos and never gambling. During his psychiatric hospitalization, treatment with olanzapine, 7.5 mg/d, plus citalopram, 20 mg/d, was started. Gambling ceased until he elected to stop taking the olanzapine 8 to 9 months later. Compulsive gambling reemerged and persisted for the next 2 years despite multiple psychiatric consultations. It subsequently remitted when his neurologist recognized pramipexole as potentially culpable and discontinued use of the drug.
Case 4.
A 53-year-old married woman recently diagnosed as having PD developed uncontrollable urges to gamble within a month of starting pramipexole monotherapy at a maintenance dose of 4.5 mg/d. Unbeknownst to her husband, she lost $50,000 at a local casino during the ensuing 3 years. Before starting pramipexole therapy, she was an indifferent gambler, going to the casino weekly with friends but frequently wagering nothing and never losing large amounts of money. When pramipexole therapy was discontinued and carbidopa/levodopa therapy maintained, the gambling completely abated.
Case 5.
An 80-year-old married man with a 16-year history of PD and gradually encroaching dementia developed hypersexuality, with the medical record documenting “some suggestion of sexual inappropriateness” toward his wife. His PD medications at that time were ropinirole, 6 mg/d, and carbidopa/levodopa, 850 mg/d. After the ropinirole dose was tapered, the medical record did not mention hypersexuality again.
Case 6.
A 69-year-old married man with a 14-year history of PD reported a 3-year history of gambling and “increased libido.” Prior to 3 years ago, he had never gambled and had gambled only since then during the summer months, “twice a day, every day,” because a casino was close to their summer home. Pramipexole, 4.5 mg/d, had been initiated a year before the onset of these behaviors after he had been taking 3 mg/d for the prior 4 years. After he reduced his pramipexole dose back to 3 mg/d, the problematic gambling remitted.
Case 7.
A 49-year-old married man with an 8-year history of PD developed a compulsive gambling habit a month after increasing his ropinirole dosage from 15 to 21 mg/d. Initially regarded as a psychiatric problem, the compulsive gambling was managed with counseling and attendance at Gamblers Anonymous meetings, which controlled the urge but did not eliminate it. A year later, his wife told the neurologist that he had “an excessive sex urge,” later necessitating a call to the police after her husband chased her when she refused sex. Other new-onset compulsions included intense focus on his hobby of making stained glass windows, often staying up all night to work on these. His appetite and alcohol intake also increased. Quetiapine was initiated at dosages up to 300 mg/d without effect on his sexual demands. He was diagnosed as having bipolar disorder, and his medical regimen was switched from quetiapine to carbamazepine without benefit. Not until the dosage of ropinirole (then 24 mg/d) was tapered and carbidopa/levodopa substituted did his pathologic behaviors remit, with his wife reporting a “complete transformation” with the levodopa and entacapone. “I have my husband back,” she said. “It was like I was married to an alien.”
PubMed Central, TABLE 3.: Mayo Clin Proc. 2009 April; 84(4): 310–316.
"The literature indicates that the risk of pathologic gambling or hypersexuality with carbidopa/levodopa monotherapy is low, which is also consistent with our findings. However, most of the described patients with PD, including our patients, have been taking an agonist concurrent with levodopa, which presumably facilitates the effect.These pathologic behaviors have been noted almost exclusively among patients with PD who have been taking dopamine agonist doses well into the therapeutic range or beyond, consistent with our findings"
"The basis for these drug-induced pathologic behaviors continues to be debated. However, it is hard to ignore the fact that the implicated dopamine agonists have unique and selective affinity for dopamine D3 receptors. Dopamine D3 receptors are primarily confined to the limbic system. Conceptually, they may prime the dopamine reward circuits to facilitate certain behaviors. Hence, patients in the current and other series often display more than 1 pathologic behavior."
