My thoughts on restless legs syndrome
I consult on many patients already treated for restless legs syndrome (RLS) before seeing me in my sleep practice. The growing recognition of RLS and its treatment is encouraging, however, I wonder if we are using pharmaceutical therapies too soon?
RLS is a relatively common neurological disorder affecting 5-10% of the population and occurring twice as often in women. RLS is associated with an increased risk of heart disease and stroke.
This blog aims to help you accurately diagnose RLS, and consider non-pharmaceutical options (including iron supplements) before initiating pharmaceutical therapy. RLS is important for its effect on (i) health, (ii) quality of life (see Image 1), and the adverse effects of treatment, namely dopamine agonists.
Do you have RLS?
As the name suggests, there is a sense of restlessness that is difficult to relieve. People also describe the uncomfortable leg sensation as:
This unpleasant sensation leads to an urge to move the legs, primarily when lying or sitting. There is some relief of symptoms with movement, with leg symptoms worse at night. RLS affects both legs, at times alternating from one leg to the other.
Next, identify and address RLS triggers, before jumping to pharmaceutical therapy.
- Medications that worsen RLS:
- antidepressants – most, except for Wellbutrin®;
- antihistamines – Benadryl, Claritin®, Zyrtec®;
- neuroleptics – risperidone, quetiapine;
- anti-nausea – metoclopramide, promethazine, chlorpromazine.
- Lifestyle factors contributing to RLS:
- caffeine-containing products (chocolate, tea, coffee, energy drinks etc).
- Laboratory evaluation:
- iron panel (serum ferritin).
My RLS patients have a serum ferritin level checked to ensure it is above 75 microgram/L and corrected with oral iron supplement otherwise. Stress and alcohol are personal triggers for my episodic RLS, while exercise helps relieve symptoms. If possible, discontinue or reduce the dose of medications identified as triggers of RLS.
Pharmaceuticals are appropriate if symptoms are severe or persist (Table 1).
Recommended RLS treatment:
- Sporadic symptoms (1-3 times/week):
- carbidopa/levodopa 25/100mg ½-2 tabs
- Long-term/chronic treatment:
- First line: gabapentin, pregabalin, gabapentin enacarbil;
- Second line: pramipexole, ropinirole, rotigotine patch.
- Refractory symptoms despite above treatments:
Side effects of dopamine agonists [levodopa, pramipexole (Mirapex®), and ropinirole (Requip®)] include loss of impulse control (hypersexuality, gambling, compulsive purchases), heart rhythm abnormalities, sleepiness, hallucinations, augmentation, nausea, vomiting, and low blood pressure. Rotigotine, a dopamine agonist patch, has less potential for side effects.
We should be mindful of the cost-benefit of RLS treatment as the path of good intentions may lead to inadvertent harm. Be safe.
Written by: Avinesh S Bhar, MD
About the author
Dr. Bhar is fellowship-trained and board-certified in sleep, critical care and pulmonary medicine. He has been in practice for over seven years and has established a telemedicine practice founded on high-value and personalized, and convenient sleep and pulmonary care. At Sliiip, we offer pulmonary and sleep telemedicine services that allows you to receive video consultation, diagnosis, and follow up care from the comfort of your home. Our online sleep doctor, Dr. Avinesh Bhar, believes that high-quality care only comes from a trustful physician-patient relationship. To find out more about our services get in touch with us today by visiting our website, or calling 478-238-3552.
- Emerging Concepts of the Pathophysiology and Adverse Outcomes of Restless Legs Syndrome. Garcia-Borreguero et al. CHEST 2020; 158(3):1218-1229
- Evaluating the Quality of Life of Patients with Restless Legs Syndrome. 2004 Jun;26(6):925-35. 10.1016/s0149-2918(04)90136-1
Image 1: Quality of Life with RLS Compared to Other Disorders
Table 1: Medications Recommended and Doses