Compulsive gambling
with extreme losses -- in two cases, greater than $100,000 -- by people
without a prior history of gambling problems has been linked to a class of
drugs commonly used to treat the neurological disorder restless legs
syndrome (RLS). A new Mayo Clinic study is the first to describe this
compulsive gambling in RLS patients who are being treated with medications
that stimulate dopamine receptors in the brain. The Mayo Clinic report
appeared in the Jan. 23 issue of "Neurology" (neurology).
The extent of this problem is unknown. Apparently, it occurs only in a
small number of RLS patients treated with drugs called dopamine agonists.
Considering this potential side effect of dopamine agonists, the Mayo
Clinic authors suggest that physicians screen all RLS patients for
compulsive behaviors while taking a thorough medical history prior to
prescribing dopamine agonists. Patients should be monitored closely for
signs of compulsive behaviors once dopamine agonist treatment has begun.
The report suggests that the compulsion to gamble worsened with increasing
doses of the dopamine agonists.
Current Report Builds on Earlier Findings
Pathological gambling is an impulse control disorder. In 2005, Mayo
Clinic physicians reported this disorder as a side effect of dopamine
agonist therapy in 11 Parkinson disease patients. "Although pathologic
gambling has already been recognized in patients with Parkinson disease who
often took high doses of dopamine agonists, the current report suggests
that pathological gambling is not restricted to patients with Parkinson
disease -- and also can occur at low dosages" explains Maja
Tippmann-Peikert, M.D., the lead author of the Mayo Clinic report on
restless legs syndrome. "Physicians should not only monitor Parkinson
disease patients for this behavior but also screen their RLS patients who
may be on much lower doses of dopamine agonists." This includes encouraging
the patient, family members and friends to report negative behaviors to the
patient's physician.
Fortunately, pathological gambling seems to be reversible when the dose
of the dopamine agonist is reduced or the patient is transitioned to an
alternative medication. It is crucial that these adjustments are initiated
before significant gambling debts develop, and relationships and careers
are damaged.
Significance of the Mayo Clinic Report
This preliminary Mayo Clinic report is the first to link pathologic
gambling to use of dopamine agonists in a disease other than Parkinson. It
is based on the experience of three patients who have RLS. Their gambling
problems were discovered during their medical evaluations at the Mayo
Clinic Sleep Disorders Center. Although three patients is a small sample
and larger studies are needed to validate these observations, the Mayo
Clinic authors believe that the possible link between dopamine agonists and
pathologic gambling behavior should be brought to physicians' attention
immediately due to the social and financial consequences resulting from the
behavior.
The Mayo Clinic neurologists found that gambling problems began, on
average, about nine months after the patients began taking one of two
dopamine agonists, pramipexole or ropinirole. Speculation is that the
gambling problems are emerging now because the newer generation of dopamine
agonists -- including pramipexole and ropinirole -- are targeting receptors
located in brain structures involved in motivation, emotion and reward
behaviors. Researchers theorize that, in some people, such strong and
specific stimulation in these neuronal pathways can prompt compulsive,
pleasure-seeking behaviors such as pathological gambling.
Patient Example
One patient, a woman seen in the Mayo Clinic Sleep Disorders Center,
had a five-year history of regular nighttime creeping-crawling sensations
in her legs, accompanied by the strong urge to move her legs. Two and a
half years prior to her Mayo Clinic visit, she had been diagnosed with RLS
and treatment with pramipexole was begun.
Her symptoms improved, however, a problematic behavior developed soon
after she started taking the medication. She developed an uncontrollable
urge to gamble when visiting the nearby casino. As the dose increased, her
gambling compulsion grew stronger. The transition of her therapy to another
dopamine agonist, ropinirole, further increased her compulsion to gamble.
Prior to her treatment for RLS, she had no history of gambling and viewed
gamblers as "unfortunate individuals," the authors report. The patient lost
more than $140,000 from gambling.
Mayo Clinic physicians discontinued the dopamine agonist therapy and
her urge to gamble completely disappeared, but the troublesome leg
sensations returned. Her RLS is now successfully treated with a
non-dopamine agonist, gabapentin, and she has no side effects, according to
the authors.
Collaboration
The Mayo Clinic team also included: John Park, M.D.; Bradley Boeve,
M.D.; John Shepard, M.D.; and Michael Silber, M.B.Ch.B.
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View drug information on Pramipexole.
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