Patients with Parkinson’s disease who take certain dopamine agonists may have an increased risk of compulsive gambling. According to Mark A. Stacy, MD, “The risk of gambling problems in a patient with Parkinson’s disease is very small. However, it may be appropriate for doctors to inform patients of this potential risk,” particularly if their patients have a documented history of depression or anxiety disorder and are taking high dosages of a dopamine agonist, he said.

Dr. Stacy is the Medical Director of the Parkinson’s Disease and Movement Disorders Center at Duke University Medical Center in Durham, North Carolina. He reported his team’s findings in the August 12 issue of Neurology.

HIGH-STAKES DOPAMINE AGONISTS?

Dr. Stacy and colleagues analyzed the data of 1,884 patients with Parkinson’s disease who were observed during a one-year period at the Muhammad Ali Parkinson Research Center in Phoenix. A total of 529 patients were treated with pramipexole, 421 with ropinirole, and 331 with pergolide. The researchers found that nine patients (seven men and two women) developed pathologic gambling problems. These nine patients were taking both levodopa and a dopamine agonist. Eight of the patients took pramipexole as their dopamine agonist, and one patient was taking pergolide. None of the other patients taking ropinirole or only levodopa had a gambling problem.

The majority of the patients were in advanced stages of Parkinson’s disease, according to Dr. Stacy. On average, they had been diagnosed with the disease more than 11 years before their gambling problems began. The patients were taking pramipexole or pergolide anywhere from six to 64 months before the onset of gambling, and seven patients started gambling within one month of an increased dosage of the dopamine agonist. None had a history of gambling.

A RARE BUT SERIOUS PROBLEM

Some patients developed serious financial problems as a result of their gambling; two had losses of more than $60,000 each. For most patients, the gambling was controlled or stopped under a new treatment plan. For eight patients, the dopamine agonist was switched to lower comparative dosages of ropinirole, and the remaining patient received a decreased dosage of pramipexole and an increased dosage of levodopa. Two of the patients who switched to ropinirole also required additional psychiatric treatment; one withdrew from the therapy program and later committed suicide after a relapse of her gambling behavior when her caregiver was out of town.

For those patients who have already developed a gambling problem, Dr. Stacy offered some practical advice for their physicians: The first step is to “reduce their dopamine agonist dosage or change to another dopamine agonist,” he told NEUROPSYCHIATRY REVIEWS. “Then, counsel families to take [control of] credit cards and other types of assets. Offer therapy for depression, refer to counseling, and provide Gamblers Anonymous information.”

Overall, the incidence of pathologic gambling in patients with Parkinson’s disease regardless of therapy was .05%. The incidence was 1.5% in the pramipexole group and .3% in the pergolide group. Dr. Stacy noted that the rate of pathologic gambling in the general population ranges from .3% to 1.3%, and therefore, the 1.5% incidence in the pramipexole therapy group “may not be unexpected.” In addition, he said, the availability of casinos in a retirement and vacation setting such as Arizona may have contributed to the development of this behavior in these patients.

“However, this clinical observation suggests that higher dosages of dopamine agonists may be a catalyst to bringing out this destructive behavior,” said Dr. Stacy. In addition, he reported, “These subjects illustrate that excessive gambling may occur in advancing Parkinson’s disease, and in this series, appeared to begin with an increase in [dopamine agonist] therapy and to resolve with dosage reduction. Given the complex world of the patient with Parkinson’s disease—dopaminergic therapy, chronic illness, and casino availability—it may be appropriate to inform subjects of a potential risk of this behavior.”

Since his team’s findings were published, “A number of people with similar problems have contacted me,” said Dr. Stacy. He added that he is considering conducting “a more formal—and more scientific—study of this issue.”

—Colby Stong

Suggested Reading
Driver-Dunckley E, Samanta J, Stacy M. Pathological gambling associated with dopamine agonist therapy in Parkinson’s disease. Neurology. 2003;61:422-423.
Molina JA, Sainz-Artiga MJ, Fraile A, et al. Pathologic gambling in Parkinson’s disease: a behavioral manifestation of pharmacologic treatment? Mov Disord. 2000;15:869-872.

Return to table of contents