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Restless Legs Syndrome

Restless Legs Syndrome. What is RLS?. Diagnostic criteria (all criteria must be met) Urge to move legs, usually accompanied by uncomfortable, unpleasant sensations in legs Begins or worsens during rest or inactivity   Partially or totally relieved by movement

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Restless Legs Syndrome

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  1. Restless Legs Syndrome

  2. What is RLS? • Diagnostic criteria (all criteria must be met) • Urge to move legs, usually accompanied by uncomfortable, unpleasant sensations in legs • Begins or worsens during rest or inactivity   • Partially or totally relieved by movement • Only occurs or worsens in the evening or night • Not attributable to another condition

  3. What symptoms should prompt clinicians to consider RLS? • Insomnia • Urge to move the legs or leg dysesthesia • Other common symptoms • Leg pain • Fatigue • Leg jerks • Daytime sleepiness

  4. What physical examination findings indicate possible RLS? • No physical findings are associated with idiopathic RLS • RLS may accompany • Low iron stores • Pregnancy • Renal disease • Diabetes • Neuropathy

  5. What other evaluation should be performed in patients suspected of having RLS? • Assess • Timing and severity of RLS symptoms • Impact on daytime mood and function • Medical history • Symptoms of other sleep disorders • Family history • Medication use • Some experts recommend iron studies, even in absence of anemia continued…

  6. Common mimics • Leg cramps • Neuropathy • Arthritis • Peripheral vascular disease • Akathisia • Refer to sleep specialist or neurologist • Uncertain diagnosis or coexisting sleep disorder • Neurologic disorder or other complex medical condition

  7. CLINICAL BOTTOM LINE: Diagnosis... • Diagnosis is based on clinical criteria • Symptom timing, frequency, and severity are important • History and physical exam distinguishes RLS from mimics • Other diagnostic studies only for possible associated conditions (iron deficiency)

  8. What nondrug therapies should clinicians recommend for RLS? • Distracting activities • Mental-alerting strategies (knitting, video games) • Activities requiring standing, locomotion, movement • Activities that may improve symptoms • Pneumatic compression devices • Near-infrared light-treatment • Aerobic or resistance training, intradialytic exercise • Avoid drugs that might provoke RLS • Avoid sleep deprivation • The role of supplemental iron is uncertain

  9. How should clinicians choose and dose drugs? • Mild or intermittent symptoms • Only use pharmacologic therapy for situations that limit mobility (e.g., air travel) • Moderate or severe symptoms that interfere with sleep or impair daytime functioning • Reserve drugs for those with near daily or daily symptoms • Dopamine agonists (pramipexole, ropinorole, rotigotine) • Alpha-2 delta ligands (gabapentin encarbil) • Off label: other alpha-2 delta ligands and opioids

  10. Dopamine agonists • Recommended for patients with very severe RLS, comorbid depression/dysthymia, and obesity/metabolic syndrome • Initiate with lowest recommended dose • Don’t exceed in 24-hour period: 1 mg pramipexole; 4 mg ropinirole; 3 mg rotigotine • For pramipexole and ropinirole: take 1-2 hours before expected symptom onset • Side effects: nausea, somnolence, and site application reactions with rotigotine, impulse control disorders • Augmentation is possible • Worsening of symptoms earlier in the day • Increased intensity or spread of symptoms to the arms

  11. Alpha-2 delta ligands • Recommended for patients with comorbid pain, anxiety, insomnia, or previous impulse control disorder or addiction • Gabapentin is poorly absorbed • Gabapentin encarbil is a pro-drug that provides better bioavailability and is FDA-approved for RLS • Pregabalin is another option • Adverse effects include dizziness, somnolence, weight gain, and depression/suicidal ideation

  12. Other Medications • Benzodiazepines generally ineffective for RLS • Opioids not well-studied for RLS • Potential to improve symptoms but high rate of AEs • Only consider after other strategies are exhausted and potential for misuse is carefully assessed • Consult with a sleep specialist before prescribing

  13. How should clinicians monitor patients? • Titrate to lowest effective dose • Monitor for side effects and augmentation • Reassess patients who don’t improve for changes in aggravating factors • Beware of rebound with shorter-acting medications • Consider natural disease progression and variation • If augmentation occurs, split dose or switch to longer-acting agent in same class • Consider substituting alpha-2 delta ligand or high-potency opioid for dopaminergic agent

  14. When should clinicians consider consulting a sleep specialist or neurologist? • Atypical presentation of symptoms • Loss of treatment efficacy despite increased dosage • Intolerable side effects • Augmentation • Coexisting sleep disorder, neurologic disorder, or other complex medical conditions

  15. CLINICAL BOTTOM LINE: Treatment... • Nonpharmacologic therapies • Distracting activities • Planned ambulation • Avoiding putative triggers may not alleviate symptoms • Consider iron supplementation on a case-by-case basis • Pharmacologic treatment • Only for moderate-severe and bothersome symptoms • Start with alpha-2 delta ligands • Dose prior to expected symptom onset and titrate to lowest effective dose • Monitor for side effects • Refer patients with loss of efficacy, adverse effects, or augmentation to a sleep specialist or neurologist

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