Pramipexole, Ropinirole, and Mania in Parkinson’s Disease

Ms. A was a 37-year-old white woman with a 4-year history of Parkinson’s disease. Her family history revealed a paternal grandmother with a single major depressive episode and a sibling with anorexia nervosa. Her Parkinson’s disease symptoms had been treated with levodopa and selegiline with moderate response. Because of episodic rigidity and dyskinesia, pramipexole was added to her treatment regimen and increased to 1.5 mg b.i.d., with improvement of motor symptoms. However, in the first week after its addition, she developed symptoms of elevated mood, increased sex drive, energy, psychomotor activity, and decreased need for sleep. After 6 months on this regimen, she developed irritability, paranoia, and delusions of jealousy. Selegiline and pramipexole were discontinued, and she began taking quetiapine, titrated to 50 mg, at bedtime. Her psychotic symptoms resolved in 1 month. Quetiapine was discontinued without symptom recurrence. Two months later, her levodopa dose was decreased because of tremors and dyskinesias, and ropinirole was added and titrated to 0.75 mg t.i.d. She rapidly developed insomnia, increased energy, and agitation. Consequently, ropinirole was discontinued, which led to symptom resolution. She remained stable taking levodopa alone for several months. Ropinirole was reinstituted but led to reemergence of manic symptoms, necessitating discontinuation, which resulted in amelioration of mania.