Restless Leg Syndrome Treatment Side Effects Gambling

1. How To Treat Restless Leg Syndrome
2. Natural Treatment For Restless Leg Syndrome
3. Restless Leg Syndrome Treatment Doctors
4. What Causes Restless Leg Syndrome

Dopaminergic agents are commonly used and effective treatments for restless legs syndrome (RLS), a disabling sensorimotor disorder. Less known are some of the potentially disabling side effects of these treatments, particularly iatrogenic gambling addiction, as is described here. Good sleep routine. Throwing off your sleep pattern can make your RLS symptoms worse. Ruling out potential causes. Your first step in addressing RLS should be to figure out if something is. Side effects include constipation, dizziness, nausea, exacerbation of sleep apnea, and the risk of addiction; however, very low doses are often effective in controlling symptoms of RLS. Parkinson's Drugs May Lead to Compulsive Gambling, Shopping, and Sex An analysis of 10 years of FDA data offers compelling evidence that common Parkinson’s drugs, which are also used to treat.

DOPAMINE AGONISTS, ROPINIROLE AND PRAMIPEXOLE, ARE THE ONLY FDA-APPROVED RESTLESS LEGS SYNDROME (RLS) THERAPIES. AS SUCH, THESE TWO dopamine agonists are considered the first line of treatment (generally at low doses) for RLS in current evidenced-based guidelines. Dopamine agonists have long been used at higher doses to treat Parkinson disease (PD), and compulsive behaviors are well known to be associated with dopamine agonist use at these levels. In a small number of case reports, however, gambling has been observed in individuals with RLS who were treated on a low dose of dopamine agonists.^– In addition, Ondo and Lai reported that of 89 RLS patients treated with dopamine agonists, 7 manifested compulsive shopping behaviors and 2 manifested gambling, though none were reported to manifest the compulsive eating reported in some PD cases. The authors noted that a failure to identify similar compulsive behavioral patterns among RLS and PD patients likely related more to the higher dopamine agonist treatment range in PD rather than to specific neurobiological etiologies underlying the two disorders. Thus, Ondo and Lai speculated that the potential for RLS patients to develop compulsive behaviors may be less noticeable given the smaller doses of dopamine agonists used to treat those patients.

Here, we describe a case of a 66-year-old woman with RLS diagnosed 14 years previously. She had been treated with levodopa, ropinirole, and pergolide at various times during the course of her RLS, without improvement in her symptoms. For 7 years she was successfully managed solely on pramipexole at a maximum dose of 0.25 mg daily, but eventually the patient’s symptoms grew more intense and began occurring earlier in the day. Her neurologist recommended she increase the pramipexole dose to 1.0 mg daily. After she had been on this dosage for one year without much improvement, she was referred to the RLS specialty team at our center for a second opinion.

After a thorough history and physical exam, it was concluded that this patient’s worsening symptoms were due to either disease progression or more likely, drug-induced augmentation. Due to strong suspicion of the latter, gabapentin was started with the goal of weaning off pramipexole. A few weeks later, she sent a letter describing the “change in her habits” that only became apparent after tapering the pramipexole (see excerpt). She also reported a conscious compulsion for nocturnal eating leading to a 9-pound weight gain while on pramipexole with a documented weight loss after stopping it. Interestingly, when initially seen in clinic, this patient did not report any compulsive behaviors despite being directly questioned about them. At a follow-up clinic visit, she reported feeling like her “normal self” and her husband stated he “has his old wife back after 7 years.”

DISCUSSION

Symptoms such as compulsive behaviors are evident in people with attention deficit hyperactivity disorder, which has been linked with RLS. Yet, in this report we describe a patient with RLS with no premorbid history of attention deficit disorder or compulsive behaviors, who began to demonstrate such behaviors only in relation to dopamine agonist administration. This case also highlights the lack of patient insight into her behaviors; she only became aware of her compulsive eating and shopping after she stopped the pramipexole. Furthermore, the pramipexole dose had been relatively low (0.25 mg per day) when the compulsive shopping began, a behavior that could be corroborated by the patient’s credit card records and her husband’s account of past events.

With a low dose of dopamine agonist, our patient’s compulsive behaviors, evident only in hindsight, were not as dramatic as the reports of excessive gambling or sexual urges reported for some patients with PD taking high doses of dopamine agonists. It would not be unusual, therefore, for subtle compulsive behaviors, such as those described in this case, to go undetected initially. Even the stronger compulsive behaviors of patients with PD taking dopamine agonists are not generally seen as a problem until the consequences, such as a major loss of money, call attention to the behaviors.

The descriptions of compulsive behaviors in the PD population have led some investigators to speculate whether the behaviors result from the neurodegenerative process of PD or represent a specific effect of dopamine agonists. Demonstration of such behavior in non-PD cases and at lower doses of dopamine agonist administration suggests that subtle compulsive behaviors may be more prevalent than previously recognized by patients and treating providers. This phenomenon, which has now been reported in the RLS population, may provide additional insight into the underlying etiology of compulsive behaviors and suggest a larger neuropharmacological role played by dopamine agonists.

While most neurologists may be familiar with RLS augmentation and simple progression of the disease, many may not be aware of the aberrant behaviors that may arise in the process of treating this condition with dopamine agonists. It might be worth considering use of compulsive behavior scales during dopamine agonist treatment for RLS patients to bring attention to and further understanding of the prevalence and degree of this problem within the RLS population.

Excerpt

“I heard an ad for Mirapex on TV and the word ‘compulsive’ was mentioned. Let me tell you about my problem and PLEASE keep this confidential. My husband does not know this. In the past few years I have been shopping compulsively and have now run my credit card debt up to over $40,000. Just recently, I have sat back and tried to examine why this happened. I never used to be this way. Since I started the new regimen with Neurontin I have also noticed that my behavior is not so compulsive and I am not reckless with my spending. In fact, I no longer have an interest in shopping.”

DISCLOSURE STATEMENT

This was not an industry supported study. Dr. Allen has received research support from GlaxoSmithKline and Sepracor; has consulted for GlaxoSmithKline, Boehringer Ingelheim, UCB, Xenoport, Sepracor, Novartis, Orion Pharma, Respironics, IM Systems, Pfizer, Jazz, and Schwarz Pharma; has participated in speaking engagements for Boehringer Ingelheim and GlaxoSmithKline; and has financial interests in IM Systems. Dr. Earley has received financial considerations for attendance of a meeting for Xenoport; has consulted for UCB; and has received honorarium from Boehringer Ingelheim for serving on a faculty for a symposium on RLS. Dr. Gamaldo has participated in a speaking engagement for Pfizer. Dr. Salas has indicated no financial conflicts of interest.

REFERENCES

How To Treat Restless Leg Syndrome

Reminder of important clinical lesson

Abstract

Dopaminergic agents are commonly used and effective treatments for restless legs syndrome (RLS), a disabling sensorimotor disorder. Less known are some of the potentially disabling side effects of these treatments, particularly iatrogenic gambling addiction, as is described here. Here the authors present a 62-year-old man, with a 20–year history of RLS, who developed gambling addiction while on dopaminergic treatment. He was not forewarned of this side effect, nor was he ever screened for gambling behaviours prior to or during treatment. Eight months after discontinuation of dopaminergic treatment and after 10 sessions of cognitive–behavioural therapy for gambling addiction, his gambling behaviours have partially resolved. To our knowledge, this is the first ever first person account of this condition. To prevent the devastating consequences of gambling addiction or to minimise its impact by early intervention, the authors call for clinicians involved in treatment of RLS to follow these simple measures: screen patients for gambling behaviours prior to the onset and during dopaminergic treatment; forewarn patients of this potential side effect; and if patients screen positive, refer them to specialist gambling treatment services, in addition to making necessary changes to their medication regime.

Background

Introduction

Restless legs syndrome (RLS) can often be a very disabling sensorimotor disorder. Although there are no UK-based prevalence studies, international studies have found rates of between 3% and 10%. The four essential diagnostic criteria for RLS are: urge to move, onset or exacerbation with rest, relief with movement and night time onset or worsening of symptoms. Although the precise pathophysiological mechanisms underlying RLS have not been clearly elucidated, some point to dopaminergic depletion, thereby implicating the nigrostriatal dopaminergic loop. Given this etiological explanation, it follows that dopaminergic drugs such as levadopa/carbedopa, ropinirole, pramipexole and pergolide can be useful treatments in alleviating the symptoms of RLS. Although not very common, impulse control disorders (such as gambling addiction, which is the focus of this case report) are potentially devastating side effects of dopaminergic treatment.^– Gambling addiction and other impulse control disorders have previously been reported as a common side effect of dopaminergic treatment for Parkinson’s disease – a disorder sharing several commonalities with RLS, in its underlying aetiology, characteristics and treatment. However, iatrogenic gambling addiction as a result of dopaminergic treatment for RLS has been less studied, although some case reports and prevalence surveys have emerged recently (see discussion section); and clinicians and patients are not adequately aware of this.

Hence this side effect (iatrogenic gambling addiction), during the course of treatment for RLS, often goes unrecognised and unaddressed, leading to even more detrimental consequences for the affected individual and family. What motivated us to share this patient’s story was his comment to one of the authors, ‘they should have forewarned me that this medication could turn me into a gambler. Then things would not have got as bad as they did, and certainly I would not have blamed myself’. Through this case description, we hope to raise clinicians’ awareness of this iatrogenic condition and we call for more regular screening for gambling behaviours prior to and during treatment with dopaminergic agents.

Case presentation

Given below is the patients own account of his gambling addiction, a direct consequence of dopaminergic treatment for his RLS.

‘I am a 62-year-old retired school teacher, and this is my story of how I turned into a gambler, or to be more precise, how I was turned into a gambler. I had restless legs ever since I can remember; started very early in childhood I think. My father had it too. About 20 years ago, it became more of a concern, so I went and saw my general practitioner. He referred me to a neurologist for specialist treatment. The neurologist started me on dopaminergic medications (sinemet and cabergoline). I have been on some medication or the other since. Medications make my condition better and I sleep better. Apart from this, my life was okay until I retired about 2 years ago. I had never gambled, except for a flutter, once a year – a pound or so, on the Grand National; nothing more, ever.

So, I had been on these medications (sinemet and cabergoline, then cabergoline was switched to ropinirole, later changed to rotigotine) for over 18 years and I was doing good. It was when I retired 2 years ago that I started gambling. It started with minor stuff, like the bets you could make in the daily papers – I started betting for no money. But very soon, I was going to the bookies, round the corner from where I lived. I would bet on horses, football matches and also play blackjack and slot machines. Before I realised, it escalated from once or twice a week to an everyday pastime. Actually, it became more than a pastime. And from spending a couple of pounds a week, I had got to spending hundreds of pounds everyday: I was hooked. I had to do it whether I had the money or not. I would lie, borrow or steal from home. I would ask anyone and everyone. Because I knew I could win and then could pay it all back. I even started to gamble online, so no one had to know and I did not even have to get out of the house. In those 2 to 3 mad years, I lost over £50,000. Apart from the money side of things, I lost the respect of my family as well: my kids hated me and my wife blamed me for it. I lost my ambition in life, apart from the need to gamble. I had no time for anything or anyone else.

Natural Treatment For Restless Leg Syndrome

All this time, I was not associating my gambling with the medication. How was I to know? One time, at my sixth monthly check up with my specialist, I told him and he immediately switched my medication. He also referred me to the gambling clinic. And then over the next few months I stopped gambling, or nearly stopped. I am still frightened because the cravings are still there. Say, every time I walk past a betting shop, if I have money in my pocket, I’m scared, or when I get an e-mail offering a £5 free bet. I have had a few lapses in the past few months. The way I control my gambling these days is by controlling my lifestyle; having other things to do. I go for walks, swim and read a lot. I have got my ambition back and I’m me again. My family is beginning to trust me again. My advice to others would be – do not ever get into a betting shop if you are on this medication. And to doctors – please forewarn your patients about this side effect so it can be nipped in the bud. And to fellow patients- certainly, do not blame yourself, and get help as soon as you can’.

Treatment

The patient received 10 sessions of individual cognitive–behavioural therapy for his gambling addiction, between September 2010 and March 2011. Key issues discussed in these sessions were: the role of behavioural conditioning in gambling and triggers for the occasional lapses (seemed to mostly involve complacency with regard to both carrying reasonably large amounts of cash and a lack of foresight when entering into high-risk situations). Discussions also encompassed the patient’s lifestyle and adaptation to retirement. Finally, the need for roles in order to provide a sense of purpose and impose some structure on his spare time was also discussed.

Outcome and follow-up

Details of the patient’s treatment aspects are covered in other sections. In summary, the patient has, since completion of his 1:1 cognitive–behavioural therapy in March 2011 been completely abstinent from gambling. He still reports occasional cravings, especially triggered by high-risk situations such as walking past betting shops and getting e-mail reminders from online betting schemes. He is highly motivated to continue total abstinence from gambling. He spends more time with his family and keeps himself busy by pursuing other recreational activities.

Discussion

The subject of dopaminergic treatment – induced gambling addiction in patients with RLS had not been sufficiently explored until recently. But encouragingly, over the past few years researchers have attempted to understand this area better. In perhaps one of the earliest accounts Driver–Dunckley et al studied 77 patients with idiopathic RLS who were on one or more dopaminergic medications, for medication-induced gambling behaviours and other compulsions. They found that 6% of their sample had increased urges to gamble and spent increased time gambling, specifically after the initiation of dopaminergic medication. In a similar and more recent study, Dang et al found the prevalence of impulse control disorders (ICDs) in this cohort of patients to be 2.7%; these ICDs included gambling addiction, kleptomania, compulsive shopping and hypersexuality. They failed to establish a linear relationship between duration of dopaminergic treatment and risk of onset of ICDs, but found that some of these iatrogenic symptoms persisted beyond cessation of dopaminergic treatment. This combined with the multiple financial, forensic, social and marital implications of these behaviours they found in this study made them call for ‘careful consideration by clinicians of the emergence of ICDs and discussion with patients.

Restless Leg Syndrome Treatment Doctors

In perhaps the most comprehensive review to date, of all cases published, of patients with RLS who developed gambling addiction while on dopaminergic therapy, d’Orsi et al identified 15 cases. Key features found in this review included the following: average age of onset was 59.8 (range was 27 to 77), gender distribution – male: female was 7:8, they were all on dopaminergic monotherapy, they had all been on treatment for several months, some also experienced other compulsive behaviours, none had a history of gambling addiction but four were recreational gamblers in the past, and gambling addiction ‘improved-resolved’ in all patients upon cessation of dopaminergic treatment.

In light of the above published evidence, the patient’s case described above seems not uncommon and fits with previous reports. The patient had suffered from RLS since early childhood and he had a family history of RLS. He commenced dopaminergic treatment at the age of 40, with sinemet and cabergoline. His symptoms of RLS were reasonably well-controlled initially but as he developed an augmentation phenomenon, he was switched from cabergoline to ropinirole. On this medication, although his symptoms of RLS improved, he developed a gambling problem; he had had no history of such a problem. As soon as this was identified, he was switched to rotigotine but his addiction to gambling persisted. It was then that his medication was changed over to gabapentin and he was also referred to the gambling clinic. He received 10 sessions of cognitive–behavioural therapy for his gambling addiction. Six months on, he is no longer addicted to gambling but he has had a few lapses. His symptoms of RLS are better controlled but he still struggles to get a refreshing night’s sleep.

In our view what makes this case unusual from previous ones and hence all the more relevant to the clinician are the following. First, the patient was never forewarned about this potential side effect (i.e. gambling addiction) any time before, nor was he ever screened for gambling behaviours during his dopaminergic treatment. Second, it was not until well over 18 years of dopaminergic treatment that he developed gambling addiction. Third, while it would appear that the patient’s gambling is in remission 6 months after cessation of dopaminergic treatment, he still continues to have cravings and occasional lapses into gambling. Hence we call for clinicians involved in treatment of RLS to follow these simple measures: screen patients for gambling behaviours prior to the onset and during dopaminergic treatment; forewarn patients of this potential side effect; and if patients screen positive, refer them to specialist gambling treatment services, in addition to making necessary changes to their medication regime; consider collaborative working between neurologists and addiction specialists in treating these patients.

In conclusion, we hope this patient’s story has succeeded in raising clinicians’ awareness of this condition. We end with a call to forewarn patients of this side effect (i.e. iatrogenic gambling addiction) of dopaminergic medications, and stress the importance of regularly screening patients for the development of gambling behaviours.

• ▶ Iatrogenic gambling addiction is a less known side effect of dopaminergic agents, commonly used treatments for RLS.
• ▶ But very often this side effect goes unrecognised and hence unaddressed.
• ▶ We call for clinicians to forewarn patients of this potential side effect and to screen patients for gambling behaviours prior to the onset and during dopaminergic treatment.
• ▶ If patients screen positive, refer them to specialist gambling treatment services, in addition to making necessary changes to their dopaminergic medication regime.

Acknowledgments

We thank the patient for agreeing to share his story.

Footnotes

Competing interests None.

Patient consent Obtained.

References

What Causes Restless Leg Syndrome