Download Restless Legs Syndrome

Restless Legs Syndrome
David Atkins
2-28-08
PAS 645-646
What is RLS ?
• Restless Legs Syndrome (RLS) is a
sensorimotor movement disorder.
• Characterized by:
– an uncontrollable urge to move the legs
– symptoms typically begin in the evening or at
bedtime, preventing the sufferer from falling
asleep
Is RLS even REAL?
YES.
HISTORY of RLS
• Phenomenon was described as early as
17th century by Thomas Willis.
• Closely observed in 1945 by Karl-Axel
Ekbom who coined the term "Restless
legs" (formerly called "Ekbom-syndrome").
• Diagnostic criteria outlined by International
RLS Study Group (IRLSSG) in 1995.
Revised in 2003.
Epidemiology
Roughly 10% prevalence in the general
population of U.S. and Western Europe.
Significantly lower rates in African
Americans.
Higher incidence in women?
Etiology
• IDIOPATHIC
• Genetic Linkage: 3 separate loci have
been identified, none solely responsible.
• Most research is aimed at dopamine
and/or iron pathologies.
Two Forms of RLS:
• Primary (idiopathic):
Secondary RLS:
• Early onset: usually
manifests before 45
• Later age of onset
• Familial: >60% have at
least 1 primary family
member with RLS.
• No family history of RLS
• More gradual progression
of Sx over time.
• Rapid progression of Sx.
Secondary RLS
• Usually related to disorders that result in
iron deficiency.
• Most common underlying causes of
secondary RLS:
– Pregnancy
– Anemia
– End-stage renal disease
– ADHD
Diagnosing RLS
Treating RLS
• There is no cure, Tx is symptomatic only
• Pharmacologic vs. Non-pharmicologic
• Many treatments out there, but all lack
sufficient research…studies are ongoing.
ALWAYS try non-pharm. Tx
Behavioral/Lifestyle
modification:
Practice good sleep hygeine
Regular moderate exercise,
but at the right times
Other anecdotal methods
st
1
Avoid Sx aggravators:
caffeine
nicotine
alcohol
diphenhydramine
TCA's
SSRI's
neuroleptics
NON-Pharmacologic Tx:
IRON
• Iron supplementation: 50-65mg tid (+Vit C)
• IV: sodium ferric gluconate or iron sucrose
• Only beneficial if serum ferritin <50μg/L
Pharmocologic Tx
• DA-agonists are drugs of choice:
– Levadopa (d.o.c. for intermittent RLS)
– Ropinirole (Requip®) FDA approved for RLS in
May, 2005.
– Pramipexole (Mirapex®) FDA approved for RLS
in November, 2006.
• Both indicated for moderate-severe RLS.
• No studies (yet) comparing ropinirole to pramipexole
Other Rx options:
• Opioids
• Benzodiazepines
• Anti-convulsants
• BZDP's: very popular before DA-agonists
became first line, with good results.
• Both BZDP's and Opioids have low dependence
and abuse potential when used for RLS
Pharmacologic Tx
As a clinician...
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Diagnose RLS using essential criteria.
-Consider +FH, underlying cause, and assess iron status
Educate patient and attempt nonpharmacologic therapies (d/c Sx aggravators)
If non-pharm Tx fails, Rx a dopaminergic.
If dopaminergics fail, try one of the "others".
May use combo of dopaminergic + "other".
Remember: all pts experience RLS and
respond to Tx differently.
References:
Essential Dx table:
Patrick L. Restless Legs Syndrome: Pathophysiology and the Role of
Iron and Folate. Altern Med Rev. 2007 Jun;12(2):101-12.
Common Pharmacologic drugs:
Hening WA. Current guidelines and standards of practice for restless
legs syndrome.
Am J Med. 2007 Jan;120 (1 Suppl 1):S22-7.
Tx Algorithm:
Ryan M, Slevin JT. Restless legs syndrome. Am J Health Syst Pharm.
2006 Sep;63(17):1599-612.