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Papay K, Xie SX, Stern M, Hurtig H, Siderowf A, Duda JE, Minger J, Weintraub D. Naltrexone for impulse control disorders in Parkinson disease: a placebo-controlled study. Neurology 2014; 83:826-33. [PMID: 25037206 DOI: 10.1212/wnl.0000000000000729] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Impulse control disorders (ICDs) in Parkinson disease (PD) are common and can be difficult to manage. The objective of this study was to determine the efficacy and tolerability of naltrexone, an opioid antagonist, for the treatment of ICDs in PD. METHODS Patients with PD (n = 50) and an ICD were enrolled in an 8-week, randomized (1:1), double-blind, placebo-controlled study of naltrexone 50-100 mg/d (flexible dosing). The primary outcome measure was response based on the Clinical Global Impression-Change score, and the secondary outcome measure was change in symptom severity using the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease-Rating Scale (QUIP-RS) ICD score. RESULTS Forty-five patients (90%) completed the study. The Clinical Global Impression-Change response rate difference favoring naltrexone in completers was 19.8% (95% confidence interval [CI] -8.7% to 44.2%). While this difference was not significant (odds ratio=1.6, 95% CI 0.5-5.2, Wald χ2 [df]=0.5 [1], p=0.5), naltrexone treatment led to a significantly greater decrease in QUIP-RS ICD score over time compared with placebo (regression coefficient for interaction term in linear mixed-effects model=-7.37, F[df]=4.3 [1, 49], p=0.04). The estimated changes in QUIP-RS ICD scores from baseline to week 8 were 14.9 points (95% CI 9.9-19.9) for naltrexone and 7.5 points (95% CI 2.5-12.6) for placebo. CONCLUSIONS Naltrexone treatment was not efficacious for the treatment of ICDs in PD using a global assessment of response, but findings using a PD-specific ICD rating scale support further evaluation of opioid antagonists for the treatment of ICD symptoms in PD. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that in patients with PD and an ICD, naltrexone does not significantly increase the probability of achieving response. However, the study lacked the precision to exclude an important difference in response rates.
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Affiliation(s)
- Kimberly Papay
- From the Departments of Psychiatry (K.P., D.W.), Biostatistics and Epidemiology (S.X.X.), and Neurology (M.S., H.H., J.E.D., J.M.), University of Pennsylvania, Philadelphia; Avid Radiopharmaceuticals (A.S.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (J.E.D., D.W.), Philadelphia Veterans Affairs Medical Center, PA
| | - Sharon X Xie
- From the Departments of Psychiatry (K.P., D.W.), Biostatistics and Epidemiology (S.X.X.), and Neurology (M.S., H.H., J.E.D., J.M.), University of Pennsylvania, Philadelphia; Avid Radiopharmaceuticals (A.S.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (J.E.D., D.W.), Philadelphia Veterans Affairs Medical Center, PA
| | - Matthew Stern
- From the Departments of Psychiatry (K.P., D.W.), Biostatistics and Epidemiology (S.X.X.), and Neurology (M.S., H.H., J.E.D., J.M.), University of Pennsylvania, Philadelphia; Avid Radiopharmaceuticals (A.S.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (J.E.D., D.W.), Philadelphia Veterans Affairs Medical Center, PA
| | - Howard Hurtig
- From the Departments of Psychiatry (K.P., D.W.), Biostatistics and Epidemiology (S.X.X.), and Neurology (M.S., H.H., J.E.D., J.M.), University of Pennsylvania, Philadelphia; Avid Radiopharmaceuticals (A.S.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (J.E.D., D.W.), Philadelphia Veterans Affairs Medical Center, PA
| | - Andrew Siderowf
- From the Departments of Psychiatry (K.P., D.W.), Biostatistics and Epidemiology (S.X.X.), and Neurology (M.S., H.H., J.E.D., J.M.), University of Pennsylvania, Philadelphia; Avid Radiopharmaceuticals (A.S.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (J.E.D., D.W.), Philadelphia Veterans Affairs Medical Center, PA
| | - John E Duda
- From the Departments of Psychiatry (K.P., D.W.), Biostatistics and Epidemiology (S.X.X.), and Neurology (M.S., H.H., J.E.D., J.M.), University of Pennsylvania, Philadelphia; Avid Radiopharmaceuticals (A.S.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (J.E.D., D.W.), Philadelphia Veterans Affairs Medical Center, PA
| | - James Minger
- From the Departments of Psychiatry (K.P., D.W.), Biostatistics and Epidemiology (S.X.X.), and Neurology (M.S., H.H., J.E.D., J.M.), University of Pennsylvania, Philadelphia; Avid Radiopharmaceuticals (A.S.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (J.E.D., D.W.), Philadelphia Veterans Affairs Medical Center, PA
| | - Daniel Weintraub
- From the Departments of Psychiatry (K.P., D.W.), Biostatistics and Epidemiology (S.X.X.), and Neurology (M.S., H.H., J.E.D., J.M.), University of Pennsylvania, Philadelphia; Avid Radiopharmaceuticals (A.S.), Philadelphia; and Parkinson's Disease Research, Education and Clinical Center (J.E.D., D.W.), Philadelphia Veterans Affairs Medical Center, PA.
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Abstract
OBJECTIVE To determine the frequency and correlates of impulse control and related behavior symptoms in patients with de novo, untreated Parkinson disease (PD) and healthy controls (HCs). METHODS The Parkinson's Progression Markers Initiative is an international, multisite, case-control clinical study conducted at 21 academic movement disorders centers. Participants were recently diagnosed, untreated PD patients (n = 168) and HCs (n = 143). The outcome measures were presence of current impulse control and related behavior symptoms based on recommended cutoff points for the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP)-Short Form. RESULTS There were 311 participants with complete QUIP data. Frequencies of impulse control and related behavior symptoms for patients with PD vs HCs were as follows: gambling (1.2% vs. 0.7%), buying (3.0% vs. 2.1%), sexual behavior (4.2% vs. 3.5%), eating (7.1% vs. 10.5%), punding (4.8% vs. 2.1%), hobbyism (5.4% vs. 11.9%), walkabout (0.6% vs. 0.7%), and any impulse control or related behavior (18.5% vs. 20.3%). In multivariable models, a diagnosis of PD was not associated with symptoms of any impulse control or related behavior (p ≥ 0.10 in all cases). CONCLUSIONS PD itself does not seem to confer an increased risk for development of impulse control or related behavior symptoms, which further reinforces the reported association between PD medications and impulse control disorders in PD. Given that approximately 20% of patients with newly diagnosed PD report some impulse control or related behavior symptoms, long-term follow-up is needed to determine whether such patients are at increased risk for impulse control disorder development once PD medications are initiated.
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Affiliation(s)
- Daniel Weintraub
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Weintraub D, Mamikonyan E, Papay K, Shea JA, Xie SX, Siderowf A. Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease-Rating Scale. Mov Disord 2011; 27:242-7. [PMID: 22134954 DOI: 10.1002/mds.24023] [Citation(s) in RCA: 229] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 10/05/2011] [Accepted: 10/12/2011] [Indexed: 11/06/2022] Open
Abstract
Impulse control disorders and related disorders (hobbyism-punding and dopamine dysregulation syndrome) occur in 15% to 20% of Parkinson's disease (PD) patients. We assessed the validity and reliability of the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease-Rating Scale (QUIP-RS), a rating scale designed to measure severity of symptoms and support a diagnosis of impulse control disorders and related disorders in PD. A convenience sample of PD patients at a movement disorders clinic self-completed the QUIP-RS and were administered a semistructured diagnostic interview by a blinded trained rater to assess discriminant validity for impulse control disorders (n = 104) and related disorders (n = 77). Subsets of patients were assessed to determine interrater reliability (n = 104), retest reliability (n = 63), and responsiveness to change (n = 29). Adequate cutoff points (both sensitivity and specificity values >80% plus acceptable likelihood ratios) were established for each impulse control disorder and hobbyism-punding. Interrater and retest reliability (intraclass correlation coefficient r) were >0.60 for all disorders. Participants in an impulse control disorder treatment study who experienced full (t = 3.65, P = .004) or partial (t = 2.98, P = .01) response demonstrated significant improvement on the rating scale over time, while nonresponders did not (t = 0.12, P = .91). The QUIP-RS appears to be valid and reliable as a rating scale for impulse control disorders and related disorders in PD. Preliminary results suggest that it can be used to support a diagnosis of these disorders, as well as to monitor changes in symptom severity over time.
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Affiliation(s)
- Daniel Weintraub
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania 19104-2676, USA.
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Papay K, Mamikonyan E, Siderowf AD, Duda JE, Lyons KE, Pahwa R, Driver-Dunckley ED, Adler CH, Weintraub D. Patient versus informant reporting of ICD symptoms in Parkinson's disease using the QUIP: validity and variability. Parkinsonism Relat Disord 2010; 17:153-5. [PMID: 21186135 DOI: 10.1016/j.parkreldis.2010.11.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 10/19/2010] [Accepted: 11/22/2010] [Indexed: 11/17/2022]
Abstract
Questions exist regarding the validity of patient-reporting of psychiatric symptoms in Parkinson's disease (PD). We assessed observer variability and validity in reporting of impulse control disorder (ICD) symptoms in PD by using the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP). PD patients and their informants (71 pairs) completed the QUIP to assess four ICDs (compulsive gambling, buying, sexual behavior, and eating) in patients. Trained raters then administered a diagnostic interview. Sensitivity of the QUIP for a diagnosed ICD was 100% for both patient- and informant-completed instruments, and specificity was 75% for both raters. Approximately 40% of patients without an ICD diagnosis had a positive QUIP, suggesting that many PD patients experience subsyndromal ICD symptoms that require ongoing monitoring. Agreement between patient- and informant-reporting of any ICD behaviors on the QUIP was moderate (kappa=0.408), and for individual ICDs was highest for gambling (kappa=0.550). Overall, a negative QUIP from either the patient or informant rules out the possibility of an ICD, while a positive QUIP requires a follow-up diagnostic interview and ongoing monitoring to determine if symptoms currently are, or in the future become, clinically significant.
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Affiliation(s)
- Kimberly Papay
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA 19104, USA
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