Can pramipexole cause or worsen atrial fibrillation (AFib)?

Can Pramipexole Cause or Worsen Atrial Fibrillation?

Pramipexole has not been definitively linked to causing or worsening atrial fibrillation based on current clinical guidelines and evidence.

Relationship Between Pramipexole and Atrial Fibrillation

Pramipexole is a dopaminergic agonist primarily used to treat Parkinson's disease, restless legs syndrome (RLS), and periodic limb movement disorder. When reviewing the available evidence:

• Current atrial fibrillation management guidelines from major cardiology societies (ACC/AHA/ESC) do not list pramipexole among medications known to cause or worsen atrial fibrillation 1.

• The 2024 review on drug-induced atrial fibrillation does not include pramipexole among the medications associated with triggering atrial fibrillation 1.

• Clinical practice guidelines for REM sleep behavior disorder mention pramipexole as a treatment option but do not list atrial fibrillation as a known adverse effect 1.

Known Medications That Can Cause Atrial Fibrillation

Several medication classes have been documented to potentially cause or worsen atrial fibrillation:

• Anticancer drugs: Particularly ibrutinib (3-16% incidence) and other tyrosine kinase inhibitors 1
• Cardiovascular medications: Some antiarrhythmics paradoxically
• Respiratory medications: Theophylline and beta-adrenergic agonists 1
• Central nervous system agents: Some antipsychotics (particularly clozapine, chlorpromazine, olanzapine) 1
• Anticholinergic agents: Particularly those with parasympathomimetic effects 1

Pramipexole's Known Side Effects

The common side effects of pramipexole include:

• Nausea
• Orthostatic hypotension
• Headache
• Daytime sleepiness
• Impulse control disorders
• Augmentation of RLS symptoms 1

Cardiovascular side effects, particularly arrhythmias like atrial fibrillation, are not prominently featured in the safety profile.

Clinical Implications and Recommendations

If a patient on pramipexole develops atrial fibrillation:

1. Evaluate for common AF risk factors first:

   • Age (particularly >65 years)
   • Structural heart disease
   • Hypertension
   • Heart failure
   • Coronary artery disease
   • Diabetes mellitus
   • Hyperthyroidism (present in 3-5% of AF cases) 1

2. Consider the temporal relationship between pramipexole initiation and AF onset

3. Assess for other medications with stronger associations to drug-induced AF

4. Management approach should follow standard AF guidelines with consideration of:

   • Rate control (beta-blockers, calcium channel blockers, digoxin)
   • Rhythm control if appropriate
   • Anticoagulation based on stroke risk assessment
   • Treatment of any underlying disorders 1

Conclusion

While any medication can potentially affect cardiac rhythm in susceptible individuals, there is no substantial evidence in current guidelines or literature suggesting pramipexole as a significant cause or exacerbating factor for atrial fibrillation. If AF develops in a patient taking pramipexole, standard evaluation for common AF causes and risk factors should be pursued before attributing it to the medication.