A 60-year-old man with Parkinson's disease has adequate motor control but is troubled by frequent episodes of sudden-onset sleep at the wheel (sleep attacks). He is on pramipexole 1.5 mg/day and levodopa 600 mg/day. Which medication is most likely responsible for the sleep attacks?

• A Pramipexole (dopamine agonist) ✓
• B Levodopa alone
• C An unrelated primary narcolepsy diagnosis
• D Selegiline-induced insomnia causing daytime sleepiness

Explanation

Dopamine agonists (pramipexole, ropinirole, rotigotine) are strongly associated with excessive daytime sleepiness and sudden-onset sleep attacks (sleep attacks without warning), which pose a driving safety hazard. Levodopa may cause mild somnolence but is much less frequently implicated in true sleep attacks. Driving should be stopped and pramipexole dose reviewed or switched. This is a class effect of non-ergot dopamine agonists.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.