From the FDA Drug Label
5.4 Hallucinations/Psychotic-Like Behavior In double-blind, placebo-controlled, early-therapy trials in patients with Parkinson’s disease who were not treated with L-dopa, 5.2% (8 of 157) of patients treated with ropinirole reported hallucinations, compared with 1.4% of patients on placebo (2 of 147). Among those patients receiving both ropinirole and L-dopa in advanced Parkinson’s disease trials, 10.1% (21 of 208) were reported to experience hallucinations, compared with 4.2% (5 of 120) of patients treated with placebo and L-dopa. The incidence of hallucination was increased in elderly patients (i.e., older than 65 years) treated with extended-release ropinirole [see Use in Specific Populations (8.5)].
To minimize the patient's hallucinations, the best approach would be to decrease the dose of dopaminergic medications.
- Do not increase the dose of ropinirole as this may worsen the hallucinations.
- Do not add haloperidol as it may exacerbate the psychosis.
- Consider switching ropinirole to an MAO-B inhibitor, but this decision should be made with caution and under the guidance of a healthcare professional.
- Quickly stopping levodopa/carbidopa is not recommended as it may lead to withdrawal symptoms and worsening of Parkinson's disease symptoms. 1
From the Research
The best approach to minimize hallucinations in this 75-year-old man with Parkinson's disease would be to discontinue ropinirole, as it is the most likely cause of his hallucinations. Dopamine agonists like ropinirole have a higher risk of causing psychiatric side effects compared to other antiparkinsonian medications, especially in elderly patients 2, 3. The medication should be tapered gradually rather than stopped abruptly to avoid withdrawal symptoms. A typical taper might reduce the dose by 25% every 5-7 days until discontinuation. If motor symptoms worsen after ropinirole withdrawal, the levodopa/carbidopa dose could be cautiously increased to compensate.
Some key points to consider:
- Ropinirole is a dopamine agonist that can cause hallucinations, especially in elderly patients 2.
- Discontinuing ropinirole is the most likely solution to minimize hallucinations 4.
- If hallucinations persist, consider reducing entacapone next, as it increases dopamine levels by inhibiting COMT.
- For persistent hallucinations, low-dose quetiapine or clozapine could be added, as these atypical antipsychotics can treat psychosis without significantly worsening Parkinson's symptoms 4.
- Pimavanserin is another option specifically approved for PD psychosis.
It's also important to note that:
- MAO-B inhibitors like selegiline have been shown to have anti-apoptotic properties, but their use in this context is not directly related to minimizing hallucinations 5.
- Other studies have compared the efficacy of ropinirole and levodopa in the treatment of early Parkinson's disease, but this is not directly relevant to the management of hallucinations in this patient 6.
Overall, the most recent and highest quality study 4 supports the discontinuation of ropinirole as the best approach to minimize hallucinations in this patient.