How to manage hallucinations in a 71-year-old patient with idiopathic Parkinson's disease (PD) taking pramipexole (Mirapex) and carbidopa/levodopa (Sinemet)?

From the Guidelines

To manage hallucinations in a 71-year-old patient with idiopathic Parkinson's disease taking pramipexole and carbidopa/levodopa, the first step should be to reduce the dose of pramipexole to determine if these episodes of psychosis are drug-related or not, as dopamine agonists like pramipexole are known to increase the risk of hallucinations 1. The patient's current regimen includes pramipexole, which was recently increased by 75%, and carbidopa/levodopa. Given that the patient has been experiencing hallucinations, it is essential to assess the potential role of pramipexole in contributing to these symptoms.

Key Considerations

• The patient's hallucinations may be related to the recent increase in pramipexole dose, and reducing the dose may help alleviate these symptoms.
• Carbidopa/levodopa is also a potential contributor to hallucinations, but reducing the dose may compromise motor symptom control.
• Non-pharmacological approaches, such as maintaining a well-lit environment and establishing regular sleep patterns, can also help manage hallucinations.

Treatment Options

• Reducing the dose of pramipexole is the first step in managing hallucinations, as it may help determine if the dopamine agonist is contributing to the patient's symptoms.
• If hallucinations persist, consider reducing the carbidopa/levodopa dose while balancing motor symptom control.
• Pimavanserin (Nuplazid) 34 mg daily is an FDA-approved antipsychotic specifically for PD psychosis and may be considered if reducing pramipexole and carbidopa/levodopa doses is not effective.

Important Considerations

• Typical antipsychotics and risperidone should be avoided as they can worsen parkinsonism.
• Clozapine is highly effective but requires regular blood monitoring due to the risk of agranulocytosis.
• Quetiapine can be started at 12.5-25 mg at bedtime and gradually increased to 50-200 mg daily as needed.
• Educating caregivers about reassurance techniques and addressing sensory deficits with glasses or hearing aids can also help manage hallucinations.

From the FDA Drug Label

In the three double-blind, placebo-controlled trials in early Parkinson's disease, hallucinations were observed in 9% (35 of 388) of patients receiving pramipexole dihydrochloride tablets, compared with 2.6% (6 of 235) of patients receiving placebo. Hallucinations were of sufficient severity to cause discontinuation of treatment in 3.1% of the early Parkinson's disease patients and 2.7% of the advanced Parkinson's disease patients compared with about 0.4% of placebo patients in both populations. Age appears to increase the risk of hallucinations attributable to pramipexole.

The patient is experiencing hallucinations, which is a known side effect of pramipexole, especially in older adults. Reducing the dose of pramipexole may help alleviate these symptoms, as the risk of hallucinations is dose-related. Alternatively, initiating pimavanserin (NUPLAZID), a drug specifically approved for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis, could be considered 2. It is essential to weigh the benefits and risks of each option and consider the patient's overall clinical picture before making a decision. Close monitoring of the patient's symptoms and adjustment of the treatment plan as needed is crucial.

From the Research

Therapeutic Approach to Managing Hallucinations in a 71-year-old Patient with Idiopathic Parkinson's Disease

The patient's symptoms of seeing spiders, bugs, and imaginary children suggest the presence of hallucinations, a common non-motor symptom of Parkinson's disease (PD) psychosis 3. Given the patient's current medication regimen, including pramipexole and carbidopa/levodopa, it is essential to consider the potential contribution of these medications to the development of hallucinations.

Potential Causes of Hallucinations

• Pramipexole, a dopamine D2 receptor agonist, has been associated with visual hallucinations, agitation, and myoclonus in cases of overdose 4.
• Carbidopa/levodopa, a dopamine precursor, can also contribute to the development of hallucinations, particularly in patients with advanced PD.

Treatment Options for Hallucinations

• Reducing the dose of pramipexole may help determine if the hallucinations are drug-related 5.
• Pimavanserin, a selective serotonin inverse agonist, is a FDA-approved medication for the treatment of PD psychosis and has been shown to be effective in reducing hallucinations and delusions without worsening motor symptoms 5, 6.
• Other atypical antipsychotics, such as clozapine and quetiapine, may also be considered, but their use is often limited by potential side effects, such as extrapyramidal symptoms and agranulocytosis 3, 7.

Recommendations

• Reduce the dose of pramipexole to determine if the hallucinations are drug-related.
• Consider initiating pimavanserin at a low dose to manage hallucinations and delusions.
• Monitor the patient's response to treatment and adjust the medication regimen as needed to minimize side effects and optimize symptom control.