What is RLS (Restless Leg Syndrome)?
- An unpleasant creeping sensation deep in the legs when they are at rest, especially in the evening and during the night.
- fidgety or jittery legs
- discomfort rather than pain
- 1% of the population, more common in the elderly.
- Men have it more than women, one third have a family history
- movements are precipitated by rest and relieved by activity.
- 50 to 80% experience periodic limb movements during sleep
PLMS: Periodic Limb Movements during Sleep
There are repetitive limb jerks while asleep: 4 or more ankle jerks in each cluster about 30 seconds apart.
Typically in the first three hours of sleep. Sometimes associated with major sleep disturbance.
A number of conditions are associated :
- excess caffeine in tea or coffee
- poor circulation in the legs
- kidney disease
- sleep deprivation
- lack of iron or Folate
- drugs for depression
Treatment
Four major groups of drugs:
- Magnesium
- Parkinson's disease medications
- Sedatives
- Narcotics
Sleep study will confirm sleep disturbed by PLMS
trial periods without drugs every 6 - 12 months check that the drugs are still needed.
AND minimises risk of the development of tolerance to the drug & risk of abuse [narcotics]
Domperidone is the only anti-nausea drug that does not bother RLS
Magnesium is helpful in 50% eg.Magnesium Orotate 200 mg half an hour before sleep
Drugs used to treat Parkinson's Disease
Dopaminergic Drugs
Madopar / Kinson / Sinemet (Carbidopa/LevoDopa)
work on the dopamine influenced nerves in the brain
about 90% of patients will respond
a good choice if need to avoid sedative medications or for daytime
complaints which would preclude the use of sedatives.
most often used for RLS is the 25 /100 strength.
30-60 minutes before bedtime. Up to 3 tablets before bedtime
will last about 3-4 hours.
For early morning awakenings, another half to one pill can be added
works better for nighttime RLS than on daytime RLS symptoms.
nausea - avoided often if the medication is taken with food
mental effects (confusion, hallucinations, dizziness),
dyskinesia (abnormal involuntary movements which occur with long term usage).
Rebound and augmentation in 50-80% of patients, so Sinemet is likely better for mild RLS,
Rebound occurs as the drug's action is wearing off
- symptoms coming back even worse than they were before treatment.
Augmentation: the intensity of the RLS symptoms can increase,
can onset earlier and even spread to the upper limbs.
(it is rarely seen with 1-2 tablets a day).
Sifrol (Pramipexole)
Probably more effective than L Dopa
Rare but notable side effects:
Impulsive gambling or shop stealing
Sudden onset sleep bouts with little warning when starting drug - do not
drive much on day drug is started or dose increased
Initially 0.125 mg 2 hours before bed for about 1 week then 250 mg per
night.
Non-Benzodiazepine Sedatives
Stillnox(Zolpidem)
unique in sedative pills as it does not alter the sleep stages.
no reported tolerance or withdrawal problems with long term usage.
no problems with rebound insomnia
doses greater than 10 mg are no more effective
very quick onset of action - less than 30 minutes
- daytime sleepiness is extremely unusual.
Imovane (Zopiclone)
a short-acting hypnotic agent.
Side effects are similar to the shorter acting benzodiazepines, tolerance/addiction should be less common.
7.5 mg tablets. Older patients should start at 1/2 tablet.
Analgesic (pain-killing) Medications
Opiates/Narcotics
These medications are very helpful for treating RLS.
but patients can get addicted / tolerance
- generally does not happen if the medications are used to just blunt the majority of the RLS symptoms,
Intermittent use and drug holidays.
Constipation, Nausea can also be a significant problem
Added aspirin and paracetamol have no effect on RLS,
Tramadol
can be very effective for treating RLS
Eg for drug holidays from narcotics
no cross tolerance has developed.
aggravation of seizures in patients with a history of fits