Hallucination levodopa

There is an increased risk of CNS depression when tiie dopamine receptor agonists are administered witii otiier CNS depressants. When administered witii levodopa, the dopamine receptor agonists increase the effects of levodopa (a lower dosage of levodopa may be required). hi addition, when the dopamine receptor agonists are administered with levodopa, there is an increased risk of hallucinations. When administered witii ciprofloxacin, there is an increased effect of the dopamine receptor agonist. 

With most DA agonists there are the other expected signs of increased DA activity such as hallucinations, psychosis and hypotension which can be worse than with levodopa. Fortunately vomiting can be countered by giving the DA antagonist domperidone. This does not cross the blood-brain barrier and so counteracts only the peripheral (chemoreceptor trigger zone) effect of the DA agonist (Fig. 15.5). 

Side effects include dyskinesias, orthostatic hypotension, dizziness, nausea, insomnia, sleep attacks, pathologic gambling, discoloration of urine/sweat, and psychiatric effects (confusion, hallucinations, nightmares, and altered behavior). Dyskinesias caused by adding other PD drugs to levodopa may be improved by decreasing the levodopa dose. Motor complications occur in about 40% of patients within 4 to 6 years of starting levodopa.1,8,24,25,37... 

Hallucinations Dopaminergic therapy in Parkinson s disease patients has been associated with hallucinations. In clinical trials, hallucinations developed in approximately 4% of patients treated with 200 mg entacapone or placebo. Dyskinesia Entacapone may potentiate the dopaminergic side effects of levodopa and may cause or exacerbate pre-existing dyskinesia. 

The use of pergolide in patients on levodopa may cause or exacerbate pre-existing states of confusion and hallucinations or preexisting dyskinesia. 

Discontinuation of therapy Abrupt discontinuation of pergolide in patients receiving it chronically as an adjunct to levodopa may precipitate the onset of hallucinations and confusion. Discontinue pergolide gradually whenever possible, even if the patient is to remain on levodopa. 

WARNING Cases of fulminant liver failure resulting in death have occurred Uses Adjunct to carbidopa/levodopa in Parkinson Dz Action COMT inhibitor slows levodopa metabolism Dose 100 mg PO tid w/ 1st daily levodopa/carbidopa dose, then dose 6 12 h later -1- w/ renal impair Caution [C, ] Contra Hqjatic impair, w/ nonselective MAOI Disp Tabs SE Constipation, XCTOstomia, vivid dreams, hallucinations, anorexia, N/D, orthostasis, liver failure, Rhabdomyolysis Interactions T Effects OF CNS dqjressants, SSRIs, TCAs, warfarin, EtOH t risk of hypotensive crisis W/ nonselective MAOIs (phenelzine, tranylc5 promine) EMS Has been associated w/ liver failure and death may experience hallucinations concurrent EtOH use can T CNS dqjression T effects of warfarin severe D is common sevoal wks afto starting OD May cause NA and dizziness... 

Amantadine was originally introduced as an antiviral compound (see Chapter 50), but it is modestly effective in treating symptoms of parkinsonism. It is useful in the early stages of parkinsonism or as an adjunct to levodopa therapy. Its mechanism of action in parkinsonism is not clear, but amantadine may affect dopamine release and reuptake. Additional sites of action may include antagonism at muscarinic and A-methyl-D-aspartate (NMDA) receptors. Adverse effects include nausea, dizziness, insomnia, confusion, hallucinations, ankle edema, and livedo reticularis. Amantadine and the anticholinergics may exert additive effects on mental functioning. 

Geriatric Considerations - Summary Ropinirole is a nonergot dopamine agonist which directly stimulates dopamine Dj receptors. It can be used in combination with levodopa or as monotherapy. If discontinued, ropinirole should be slowly tapered because abrupt discontinuation can cause confusion, hallucinations, and a condition similar to neuroleptic malignant syndrome. 

Plan to reduce the levodopa dosage if the patient experiences hallucinations. Keep in mind that hallucinations are usually accompanied by confusion and, to a lesser extent, insomnia... 

It is an ergot preparation which has a specific dopamine receptor agonist action (acts mainly on receptors) and capable of crossing the blood brain barrier. It is less active than levodopa and used only in late cases as a supplement to levodopa. Adverse effects are vomiting hallucinations, hypotension, nasal stuffiness. 

Confusion, hallucinations, delusions, and other psychiatric reactions are potential complications of dopaminergic treatment and are more common and severe with dopamine receptor agonists than with levodopa. Disorders of impulse control may lead to compulsive gambling, shopping, betting, sexual activity, and other behaviors. They clear on withdrawal of the offending medication. 

Adverse effects Diarrhea is the most common side effect of tolcapone. As expected, /evocfopa-related adverse effects increase when tolcapone is added. These include postural hypotension, nausea, sleep disorders, anorexia, dyskinesias, and hallucinations. Most seriously, fulminating hepatic necrosis is associated with tolcapone use. Baseline and frequent, regular determinations of hepatic serum enzymes are suggested by the manufacturer. Any elevations above normal are cause for discontinuation. Because of the hepatotoxicity, tolcapone should only be used as an adjunct in patients on levodopa/carbidopa who are experiencing symptom fluctuations. 

A 73-year-old woman with a 4-year history of Parkinson s disease developed hallucinations and delusions that were interpreted as secondary effects of levodopa (187). She was given clozapine 25 mg/day and continued to take levodopa. Four days later she complained of abdominal pain. She had raised activities of serum amylase 806 IU/1 (reference range <220 IU/1), lipase 2598 IU/1 (<190 IU/1), and creatine kinase 464 IU/1 (<190 IU/1), and normal concentrations of total and direct bilirubin. Other causes of pancreatitis were ruled out. 

A 75-year-old man with a 10-year history of parkinsonism developed fever and acute delirium after taking levodopa plus trihexyphenidyl (658). He had visual hallucinations, was disoriented in time and place, and could respond only to simple questions. He was unable to stand or walk and had paratonic rigidity in all limbs and marked bradykinesia. There were occasional myoclonic jerks in the arms and legs. Deep reflexes were reduced bilaterally, and the plantar reflexes were absent. 

Pramipexole has been shown to be safe and effective when used as monotherapy early in PD (Parkinson Study Group, 1997, 2000) and in mild to moderate PD (Shannon et al., 1997). Ropinirole has also been shown to be effective in early PD (Rascol et al., 1998 Korczyn et al., 1999). In later stages of PD, dopamine agonists are usually prescribed with levodopa to achieve optimal therapeutic effects and to help moderate the motor fluctuations associated with levodopa (Pinter et al., 1999). Possible side effects of all dopamine agonists include nausea, peripheral edema, somnolence and hallucinations. Pramipexole has also been associated with compulsive behavior (Driver-Dunckley etal., 2003). 

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