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{{Restless legs syndrome}}
{{Restless legs syndrome}}


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==Medical Therapy==
==Medical Therapy==
An algorithm for treating Primary RLS (RLS without any secondary medical condition including [[Iron deficiency (medicine)|iron deficiency]], [[varicose vein]], [[thyroid]], etc.) was created by leading RLS researchers at the [[Mayo Clinic]] and is endorsed by the Restless Legs Syndrome Foundation. This document provides guidance to both the treating physician and the patient and includes both nonpharmacological and pharmacological treatments.<ref name="MayoAlgo">[http://www.mayoclinicproceedings.org/article/S0025-6196%2811%2962160-5 An Algorithm for the Management of Restless Legs Syndrome] also available [http://download.journals.elsevierhealth.com/pdfs/journals/0025-6196/PIIS0025619611621605.pdf as a pdf]</ref> Treatment of primary RLS should not be considered unless all the secondary medical conditions are ruled out. Drug therapy in RLS is not curative and is  known to have significant side effects and needs to be considered with caution. The secondary form of RLS has the potential for cure if the  precipitating medical condition ([[iron deficiency]], venous reflux/[[varicose vein]], [[thyroid]], etc.) is managed effectively.
==Overview==
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].


===Pharmacotherapy===
==Medical Therapy==
For those whose RLS disrupts or prevents sleep or regular daily activities, medication is often required.  Many Doctors currently use, and the [[Mayo Clinic]] [[Algorithm]] includes,<ref name="MayoAlgo"> </ref> medication from four categories:
In patients with mild symptoms of restless legs syndrome, no treatment may be required, although all patients should be screened for [[Iron deficiency anemia|iron deficiency]].<ref name="pmid24363103" />
 
*Pharmacologic medical therapy is recommended among patients with persistent or moderate to severe symptoms of restless legs syndrome.<ref name="pmid24363103" />
* 1) [[Dopamine agonist]]s such as [[ropinirole]], [[pramipexole]], [[carbidopa]]/[[levodopa]] or [[pergolide]]:
*Pharmacologic medical therapies for restless legs syndrome include [[dopamine agonists]], alpha-2-delta calcium channel ligands and [[opioids]].<ref name="pmid24363103">{{cite journal| author=Comella CL| title=Treatment of restless legs syndrome. | journal=Neurotherapeutics | year= 2014 | volume= 11 | issue= 1 | pages= 177-87 | pmid=24363103 | doi=10.1007/s13311-013-0247-9 | pmc=3899490 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24363103  }} </ref>
 
There are some issues with the use of dopamine augmentation. Dopamine agonists may cause augmentation.  This is a medical condition where the drug itself causes symptoms to increase in severity and/or occur earlier in the day. Dopamine agonists may also cause rebound, when symptoms increase as the drug wears off. Also, a recent study indicated that dopamine agonists used in restless leg patients can lead to an increase in [[compulsive gambling]].<ref>[http://www.mayoclinic.org/news2007-rst/3918.html "Medical Therapy for Restless Legs Syndrome may Trigger Compulsive Gambling", Mayo Clinic in Rochester, February 08, 2007]</ref>
 
* 2) [[Opioid]]s such as [[propoxyphene]], [[oxycodone]], or [[methadone]], etc.
* 3) [[Benzodiazepine]]s, which often assist in staying asleep and reducing awakenings from the movements
* 4) [[Anticonvulsant]]s, which often help people who experience the RLS sensations as painful, such as [[gabapentin]]
 
In a study of 10 patients, it was reported that partial relief with taking a supplemental magnesium salt<ref name="pmid9703590">{{cite journal |author=Hornyak M, Voderholzer U, Hohagen F, Berger M, Riemann D |title=Magnesium therapy for periodic leg movements-related insomnia and restless legs syndrome: an open pilot study |journal=Sleep |volume=21 |issue=5 |pages=501-5 |year=1998 |pmid=9703590 |doi=}}</ref> such as '''[[magnesium oxide]]''' or [[magnesium gluconate]] once or twice a day, and reducing the dose if [[diarrhea]] develops. Magnesium sulfate is the most active form; however, magnesium supplementation can cause complications for patients with renal problems.<ref>{{cite web |url=http://www.mayoclinic.com/health/drug-information/DR202644 |title=Magnesium Supplements (Systemic) - MayoClinic.com |accessdate=2007-08-08 |format= |work=}}</ref>
 
 
{| class="wikitable"
| '''Agent''' || '''Timeline''' || '''Comments'''
|-
| [[ropinirole]]  || Approved In 2005 by the Food and Drug Administration to treat moderate to severe Restless Legs Syndrome || The drug was first approved for [[Parkinson's disease]] in 1997.
|-
| [[pramipexole]] (Mirapex, Sifrol, Mirapexen in the EU) || In February 2006, the EU Scientific Committee issued a positive recommendation for approving  for the treatment of RLS in the EU.  US FDA approved Mirapex in 2006. || -
|-
| [[rotigotine]] || Currently in process for US FDA and EU approval for RLS || Delivered via a transdermal patch
|-
| [[pergolide]] || In March 2007 was withdrawn from the U.S. market || Withdrawn due to implication in [[valvular heart disease]], that was shown in two independent studies.
|}
 
====Iron supplements====
All people with RLS should have their [[ferritin]] levels tested; ferritin levels should be at least 50 mcg for those with RLS.  Oral iron supplements, taken under a doctor's care, can increase ferritin levels.  For some people, increasing ferritin will eliminate or reduce RLS symptoms. A ferritin level of 50 mcg is not sufficient for some sufferers and increasing the level to 80 mcg may greatly reduce symptoms. However, at least 40% of people will not notice any improvement. Treatment with IV iron is being tested at the US [[Mayo Clinic]] and [[Johns Hopkins Hospital]]. It is dangerous to take iron supplements without first having ferritin levels tested, as many people with RLS do not have low ferritin and taking iron when it is not called for can cause [[iron overload disorder]], potentially a very dangerous condition.
 
New results from the first ever double-blind clinical study,<ref>{{cite web |url=http://www.lakartidningen.se/engine.php?articleId=2687 |title=Järninfusioner minskar symtomen vid restless legs |accessdate=2007-07-23 |format= |work=}}</ref> performed at [[Örebro University Hospital]] show that all 29 out of 60 patients that were treated with IV-infusion of up to a total of 1000 mg of iron (in the form of [[iron saccharose]], [[Venofer]]), were markedly improved after 3 weeks. The effect lasted for 5-6 months. Those 31 receiving placebo had just a slight effect after 3 weeks that additionally disappeared rapidly.
 
The treatment was given even if iron deficiency was not shown according to [[ferritin]] levels. Worries of anaphylactic reactions did not come true. This is probably due to the form the IV iron was given. Anaphylaxis has been associated predominantly with dextran based infusions.


===Non-Pharmacotherpy===
* The treatment of restless legs syndrome must be individualized to each patient.<ref name="pmid24363103" />
Treatment for RLS is based on how disruptive the symptoms are. All people should review their lifestyle and see what changes could be made to reduce or eliminate their RLS symptoms.  These include: finding the right level of [[exercise]] (too much worsens it, too little may trigger it); eliminating [[caffeine]], [[tobacco smoking|smoking]], and [[alcohol]]; changing the diet to eliminate foods that trigger RLS (different for each person, but may include eliminating [[sugar]], [[triglycerides]], [[gluten]], sugar substitutes ([[aspartame]]), following a [[low-fat diet]], etc.); keeping good [[sleep hygiene]]; treating conditions that may cause secondary RLS; avoiding or stopping OTC or prescription drugs that trigger RLS; adding supplements such as [[potassium]], [[magnesium]], [[B-12]], [[folate]], [[vitamin E]], and [[calcium]]. Some of these changes, such as diet (particularly aspartame) and adding supplements are based on anecdotal evidence from RLS sufferers as few studies have been done on these alternatives. 
* In patients with mild symptoms, no treatment is required.<ref name="pmid24363103" />


For those who experience RLS infrequently and do not need or want to try medication, in addition to lifestyle changes they can try:
=== Treatment of restless legs syndrome ===
* Some form of exercise for several minutes such as walking, stretching, meditation, [[yoga]], etc. at bedtime
* Preferred regimen (1): [[pramipexole]]<ref name="pmid11054156">{{cite journal| author=Montplaisir J, Denesle R, Petit D| title=Pramipexole in the treatment of restless legs syndrome: a follow-up study. | journal=Eur J Neurol | year= 2000 | volume= 7 Suppl 1 | issue=  | pages= 27-31 | pmid=11054156 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11054156  }} </ref>
* Heat or cold, such as a hot or cold bath, a heating pad, a cold cloth, or a fan
** Treatment with [[pramipexole]] is started at a dosage of 0.25 mg per day, and progressively increase until the optimal therapeutic effect is obtained. 
* Soaking one's feet in hot water just prior to going to sleep
* Preferred regimen (2): [[Ropinirole]]<ref name="pmid19412490">{{cite journal| author=Kushida CA| title=Ropinirole for the treatment of restless legs syndrome. | journal=Neuropsychiatr Dis Treat | year= 2006 | volume= 2 | issue= 4 | pages= 407-19 | pmid=19412490 | doi= | pmc=2671939 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19412490  }} </ref>
* Engrossing the mind in a game, the [[computer]], or figuring something out
**It is important to take [[ropinirole]] prior to symptom onset.
* Wearing [[compression stockings]], tight [[pantyhose]], or wrapping the legs in elastic bandages
**For daily RLS, [[ropinirole]] may be started at 0.25 mg per day at 2 hours before RLS symptom onset, and then increased by 0.25 mg every 2 to 3 days until symptom relief is achieved (Silber et al 2004). Starting dose should be individualized based on RLS severity and age.
* Placing a pillow between the knees or upper-legs while lying in bed
**The effective dose for [[ropinirole]] is typically 2 mg or less.
* Eating porridge oats or almonds daily for their magnesium content
**Some patients may require doses as high as 6 mg/day.
* Hot green tea can relieve symptoms
* Preferred regimen (3): [[Carbidopa/levodopa]] 25/100 mg PO daily at bedtime<ref name="pmid24363103">{{cite journal| author=Comella CL| title=Treatment of restless legs syndrome. | journal=Neurotherapeutics | year= 2014 | volume= 11 | issue= 1 | pages= 177-87 | pmid=24363103 | doi=10.1007/s13311-013-0247-9 | pmc=3899490 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24363103  }} </ref>
* Deep breathing for one or two minutes
* Alternative regimen (1): [[Gabapentin]] 300–1200 mg daily about 1 h before bedtime.<ref name="pmid24363103">{{cite journal| author=Comella CL| title=Treatment of restless legs syndrome. | journal=Neurotherapeutics | year= 2014 | volume= 11 | issue= 1 | pages= 177-87 | pmid=24363103 | doi=10.1007/s13311-013-0247-9 | pmc=3899490 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24363103  }} </ref>
* Massage and chiropractic spinal manipulation provide significant relief for some patients.
==References==
==References==
{{reflist|2}}
{{reflist|2}}
 
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[[Category:Sleep disorders]]
[[Category:Sleep disorders]]
[[Category:Syndromes]]
[[Category:Syndromes]]
[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Primary care]]
[[Category:Needs overview]]
[[Category:Needs overview]]
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Latest revision as of 23:58, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Medical Therapy

Overview

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

Medical Therapy

In patients with mild symptoms of restless legs syndrome, no treatment may be required, although all patients should be screened for iron deficiency.[1]

  • Pharmacologic medical therapy is recommended among patients with persistent or moderate to severe symptoms of restless legs syndrome.[1]
  • Pharmacologic medical therapies for restless legs syndrome include dopamine agonists, alpha-2-delta calcium channel ligands and opioids.[1]
  • The treatment of restless legs syndrome must be individualized to each patient.[1]
  • In patients with mild symptoms, no treatment is required.[1]

Treatment of restless legs syndrome

  • Preferred regimen (1): pramipexole[2]
    • Treatment with pramipexole is started at a dosage of 0.25 mg per day, and progressively increase until the optimal therapeutic effect is obtained.
  • Preferred regimen (2): Ropinirole[3]
    • It is important to take ropinirole prior to symptom onset.
    • For daily RLS, ropinirole may be started at 0.25 mg per day at 2 hours before RLS symptom onset, and then increased by 0.25 mg every 2 to 3 days until symptom relief is achieved (Silber et al 2004). Starting dose should be individualized based on RLS severity and age.
    • The effective dose for ropinirole is typically 2 mg or less.
    • Some patients may require doses as high as 6 mg/day.
  • Preferred regimen (3): Carbidopa/levodopa 25/100 mg PO daily at bedtime[1]
  • Alternative regimen (1): Gabapentin 300–1200 mg daily about 1 h before bedtime.[1]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Comella CL (2014). "Treatment of restless legs syndrome". Neurotherapeutics. 11 (1): 177–87. doi:10.1007/s13311-013-0247-9. PMC 3899490. PMID 24363103.
  2. ↑ Montplaisir J, Denesle R, Petit D (2000). "Pramipexole in the treatment of restless legs syndrome: a follow-up study". Eur J Neurol. 7 Suppl 1: 27–31. PMID 11054156.
  3. ↑ Kushida CA (2006). "Ropinirole for the treatment of restless legs syndrome". Neuropsychiatr Dis Treat. 2 (4): 407–19. PMC 2671939. PMID 19412490.

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