What medication should be avoided in a 60-year-old man with mild motor symptoms of Parkinson's Disease (PD), dyspepsia, insomnia, and impulse control disorder, specifically an addiction to online gambling?

From the Guidelines

In this 60-year-old man with mild Parkinson's Disease, dyspepsia, insomnia, and an impulse control disorder (online gambling addiction), pramipexole should be avoided as the primary medication due to its potential to worsen impulse control disorders. The patient's history of online gambling addiction is a significant concern, and medications that can exacerbate impulse control disorders should be avoided.

• Dopamine agonists, such as pramipexole, have been associated with an increased risk of impulse control disorders, including pathological gambling, hypersexuality, compulsive shopping, and binge eating 1.
• The connection between dopamine agonists and impulse control disorders is well-established, with approximately 14-17% of PD patients on these medications developing problems like pathological gambling, hypersexuality, compulsive shopping, or binge eating.
• Instead, levodopa/carbidopa (Sinemet) would be a more appropriate choice for managing his mild motor symptoms, typically starting at 25/100 mg three times daily.
• Anticholinergic medications such as trihexyphenidyl and benztropine should also be avoided as they may cause confusion in older adults and could worsen his insomnia.
• For his dyspepsia, he should avoid medications like metoclopramide which can worsen Parkinson's symptoms by blocking dopamine receptors.
• Additionally, sedating antihistamines for insomnia should be used cautiously as they have anticholinergic properties.
• The use of levodopa may be associated with impaired nutritional status and risk for malnutrition, but this is not a significant concern in this case, as the patient's primary issue is impulse control disorder 1.
• The most recent and highest quality study on this topic is from 2022, which highlights the need to optimize our understanding of the neurobiological basis of Gambling Disorder, including genetics, impulsivity and compulsivity, and biomarkers 1.

From the FDA Drug Label

Patients should be informed that hallucinations can occur and that the elderly are at a higher risk than younger patients with Parkinson's disease There have been reports of patients experiencing intense urges to gamble, increased sexual urges, and other intense urges and the inability to control these urges while taking one or more of the medications that increase central dopaminergic tone, that are generally used for the treatment of Parkinson’s disease, including pramipexole dihydrochloride Although it is not proven that the medications caused these events, these urges were reported to have stopped in some cases when the dose was reduced or the medication was stopped.

The medication that should be avoided in a 60-year-old man with mild motor symptoms of Parkinson's Disease (PD), dyspepsia, insomnia, and impulse control disorder, specifically an addiction to online gambling, is Pramipexole. This is because Pramipexole has been associated with intense urges to gamble and other impulse control disorders, which could exacerbate the patient's existing addiction to online gambling 2.

From the Research

Medication to Avoid in Managing Mild Motor Symptoms of Parkinson's Disease

The patient in question has mild motor symptoms of Parkinson's Disease (PD), accompanied by dyspepsia, insomnia, and an impulse control disorder, specifically an addiction to online gambling. Given these conditions, the medication to avoid would be one that could potentially exacerbate the impulse control disorder or have adverse interactions with the patient's other symptoms.

Consideration of Dopamine Agonists

• Dopamine agonists, such as pramipexole, are known to be associated with an increased risk of impulse control disorders in patients with Parkinson's Disease 3, 4.
• The patient's addiction to online gambling is a form of impulse control disorder, and using dopamine agonists like pramipexole could potentially worsen this condition.

Review of Provided Options

• A. Pramipexole: As a dopamine agonist, pramipexole is associated with an increased risk of impulse control disorders, making it a medication that should be avoided in this patient's case.
• B. Entacapone: This is a catechol-O-methyltransferase (COMT) inhibitor used to treat motor symptoms of Parkinson's Disease. There is no direct evidence to suggest that entacapone would exacerbate impulse control disorders or significantly interact with the patient's other symptoms in a harmful way.
• C. Rasagiline: A monoamine oxidase B (MAO-B) inhibitor, rasagiline is used in the treatment of Parkinson's Disease. Like entacapone, there is no direct evidence suggesting rasagiline would worsen impulse control disorders or negatively interact with the patient's other conditions.
• D. Levodopa: While levodopa is the gold standard for treating Parkinson's Disease and has its own set of potential side effects and complications, it is not directly associated with an increased risk of impulse control disorders in the same way dopamine agonists are.

Conclusion Based on Evidence

Given the patient's specific condition of having an impulse control disorder (addiction to online gambling) alongside Parkinson's Disease, the medication that should be avoided is the one that could potentially exacerbate this disorder. Based on the evidence provided, dopamine agonists like pramipexole are linked to an increased risk of impulse control disorders in Parkinson's Disease patients 3, 4. Therefore, the medication to avoid in managing this patient's mild motor symptoms of Parkinson's Disease would be pramipexole.