Ropinirole Withdrawal in a 67-Year-Old Male: A Case Report

Authors' Affiliations

Nasir Notta, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Shahnawaz N. Notta, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Ashwin Jagadish, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Hezborn M. Magacha, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Rupal Shah, Department of Internal Medicine, East Tennessee State University, Johnson City, TN

Location

D.P. Culp Center Ballroom

Start Date

4-5-2024 9:00 AM

End Date

4-5-2024 11:30 AM

Poster Number

88

Name of Project's Faculty Sponsor

Rupal Shah

Faculty Sponsor's Department

Internal Medicine

Classification of First Author

Clinical Doctoral Student

Competition Type

Competitive

Type

Poster Presentation

Presentation Category

Health

Abstract or Artist's Statement

Dopamine agonists are used in managing various neurological conditions including restless leg syndrome (RLS) and Parkinson's disease. Ropinirole is a dopamine agonist that has shown great efficacy in treating RLS. Dopamine agonists act in the central nervous system thus leading to improvement in neurological conditions. Ropinirole is specifically a non-ergoline dopamine agonist that exhibits a high affinity for post-synaptic dopamine receptors D2 in the central and peripheral nervous systems. Ergoline-derived dopamine agonists, such as bromocriptine or cabergoline, are older dopamine agonists that produce their effects on multiple neurotransmitter receptors including serotonin and adrenergic receptors. Dopamine agonists may have side effects such as orthostatic hypotension, hallucinations, and decreased mental clarity. A subset of patients who taper or abruptly stop dopamine agonists may develop Dopamine agonist Withdrawal Syndrome (DAWS). DAWS can affect up to 19% of patients who taper or suspend taking dopamine agonists. Symptoms of DAWS are very diverse but include anxiety, panic attacks, agitation, irritability, fatigue, nausea, vomiting, and generalized pain. RLS is a common multifactorial neurological disorder that is estimated to affect between 5% and 10% of the general population. The mean onset occurs during the third or fourth decade of life. It is characterized by the nonpainful irresistible urge to move the legs with symptoms typically worsening at night leading to sleep issues. There has been a suspected genetic basis for RLS. Among the medications used for the treatment of RLS, ropinirole is the most studied and first-line therapy for the management of RLS. This case report details the clinical scenario of a 67-year-old male who manifested a uniquely new constellation of symptoms, including increasing confusion, emotional lability, and a headache, emerging approximately 2-3 weeks after discontinuing ropinirole treatment. Comprehensive testing including CT Head and Brain MRI ruled out structural causes and laboratory causes were ruled out after obtaining TSH levels, Vitamin B12 levels, as well as a urine drug screen. Given the negative workup, the consideration of Dopamine Agonist Withdrawal Syndrome was viewed as the likely cause of the patient’s symptoms. The patient reported significant improvement within a few hours of restarting his ropinirole. Given his significant improvement, he was discharged home and was advised to follow up with his PCP for medication reconciliation, including a possible taper of ropinirole. While there are currently no established treatments for DAWS besides ropinirole reintroduction with tapering for discontinuation, recognizing this syndrome can significantly impact patient care. The case underscores the significance of recognizing and managing DAWS during dopamine agonist therapy discontinuation to prevent potential adverse effects as well as showcasing the importance of recognizing DAWS.

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Apr 5th, 9:00 AM Apr 5th, 11:30 AM

Ropinirole Withdrawal in a 67-Year-Old Male: A Case Report

D.P. Culp Center Ballroom

Dopamine agonists are used in managing various neurological conditions including restless leg syndrome (RLS) and Parkinson's disease. Ropinirole is a dopamine agonist that has shown great efficacy in treating RLS. Dopamine agonists act in the central nervous system thus leading to improvement in neurological conditions. Ropinirole is specifically a non-ergoline dopamine agonist that exhibits a high affinity for post-synaptic dopamine receptors D2 in the central and peripheral nervous systems. Ergoline-derived dopamine agonists, such as bromocriptine or cabergoline, are older dopamine agonists that produce their effects on multiple neurotransmitter receptors including serotonin and adrenergic receptors. Dopamine agonists may have side effects such as orthostatic hypotension, hallucinations, and decreased mental clarity. A subset of patients who taper or abruptly stop dopamine agonists may develop Dopamine agonist Withdrawal Syndrome (DAWS). DAWS can affect up to 19% of patients who taper or suspend taking dopamine agonists. Symptoms of DAWS are very diverse but include anxiety, panic attacks, agitation, irritability, fatigue, nausea, vomiting, and generalized pain. RLS is a common multifactorial neurological disorder that is estimated to affect between 5% and 10% of the general population. The mean onset occurs during the third or fourth decade of life. It is characterized by the nonpainful irresistible urge to move the legs with symptoms typically worsening at night leading to sleep issues. There has been a suspected genetic basis for RLS. Among the medications used for the treatment of RLS, ropinirole is the most studied and first-line therapy for the management of RLS. This case report details the clinical scenario of a 67-year-old male who manifested a uniquely new constellation of symptoms, including increasing confusion, emotional lability, and a headache, emerging approximately 2-3 weeks after discontinuing ropinirole treatment. Comprehensive testing including CT Head and Brain MRI ruled out structural causes and laboratory causes were ruled out after obtaining TSH levels, Vitamin B12 levels, as well as a urine drug screen. Given the negative workup, the consideration of Dopamine Agonist Withdrawal Syndrome was viewed as the likely cause of the patient’s symptoms. The patient reported significant improvement within a few hours of restarting his ropinirole. Given his significant improvement, he was discharged home and was advised to follow up with his PCP for medication reconciliation, including a possible taper of ropinirole. While there are currently no established treatments for DAWS besides ropinirole reintroduction with tapering for discontinuation, recognizing this syndrome can significantly impact patient care. The case underscores the significance of recognizing and managing DAWS during dopamine agonist therapy discontinuation to prevent potential adverse effects as well as showcasing the importance of recognizing DAWS.