1/
A 73 yo woman is admitted for TIA-evaluation. While in the hospital you find her pacing the floor at night.
βI just have to move my legs at night!β
You see the blood work done by her PCP and her iron levels are⦠normal.
Whatβs going on?
A #ContinuumCase @ContinuumAAN
A 73 yo woman is admitted for TIA-evaluation. While in the hospital you find her pacing the floor at night.
βI just have to move my legs at night!β
You see the blood work done by her PCP and her iron levels are⦠normal.
Whatβs going on?
A #ContinuumCase @ContinuumAAN
2/
Whatβs your guess about the cause of her "need to move" at night?
Whatβs your guess about the cause of her "need to move" at night?
3/
All of these (but limb shaking TIA) are nocturnal movement disorders.
Of these, RLS is the most common -- particularly in patients > 65. Women are twice as likely to be affected.
So on this limited history, RLS seems most likely.
But normal iron?
All of these (but limb shaking TIA) are nocturnal movement disorders.
Of these, RLS is the most common -- particularly in patients > 65. Women are twice as likely to be affected.
So on this limited history, RLS seems most likely.
But normal iron?
4/
I was under the impression this was a condition you found only with iron deficiency, pregnancy or renal failure.
However, πpoint:
ποΈββοΈiron studies are normalized for anemia.
What is an adequate iron to prevent anemia, may be an *inadequate* iron for someone with RLS!
I was under the impression this was a condition you found only with iron deficiency, pregnancy or renal failure.
However, πpoint:
ποΈββοΈiron studies are normalized for anemia.
What is an adequate iron to prevent anemia, may be an *inadequate* iron for someone with RLS!
5/
Said differently, a patient with normal iron levels (measured in this context by ferritin and transferritin saturation) my still have an iron deficiency in the context of preventing/treating RLS.
Said differently, a patient with normal iron levels (measured in this context by ferritin and transferritin saturation) my still have an iron deficiency in the context of preventing/treating RLS.
6/
Why is this?
Itβs thought that RLS is due to an iron deficiency in the CNS! MRI studies demonstrate regional iron deficiencies in the SN, putamen, caudate and thalamus.
This may lead to activation of hypoxic pathways & a mild myelin deficit. π€―
pubmed.ncbi.nlm.nih.gov
Why is this?
Itβs thought that RLS is due to an iron deficiency in the CNS! MRI studies demonstrate regional iron deficiencies in the SN, putamen, caudate and thalamus.
This may lead to activation of hypoxic pathways & a mild myelin deficit. π€―
pubmed.ncbi.nlm.nih.gov
7/
So for RLS, the goal fasting ferritin is > 75ng/ml and transferrin sat > ~25%.
Usually ferrous sulfate 325 mg BID is used with 100-200mg of Vit C for absorption.
So for RLS, the goal fasting ferritin is > 75ng/ml and transferrin sat > ~25%.
Usually ferrous sulfate 325 mg BID is used with 100-200mg of Vit C for absorption.
8/
Some patients require much higher ferritin levels before RLS symptoms abate.
Patients with persistent RLS can be given IV iron (such as ferric carboxymaltose 1000mg over 1 hour). This may be effective even in patients who have relatively high ferritin levels
Some patients require much higher ferritin levels before RLS symptoms abate.
Patients with persistent RLS can be given IV iron (such as ferric carboxymaltose 1000mg over 1 hour). This may be effective even in patients who have relatively high ferritin levels
9/
Other treatment considerations in patients with RLS. Anti-psychotics and SSRI anti-depressants (except bupropion) can cause or aggravate RLS, and these medications should be minimized to extent possible.
Other treatment considerations in patients with RLS. Anti-psychotics and SSRI anti-depressants (except bupropion) can cause or aggravate RLS, and these medications should be minimized to extent possible.
10/
Dopamine agonists like pramiprexol or ropinirole = helpful.
Yet they can cause augmentation. Meaning that they are effective in the short term, but with time they stop being effective and pts experience symptoms even earlier in the day.
They can also cause impulsive behavior
Dopamine agonists like pramiprexol or ropinirole = helpful.
Yet they can cause augmentation. Meaning that they are effective in the short term, but with time they stop being effective and pts experience symptoms even earlier in the day.
They can also cause impulsive behavior
10/
Alpha-2-delta ligands like gabapentin enacarbil can also be effective.
You are about to google βare gabapentin encarbil and gabapentin the same?β
Been there, done that:
Alpha-2-delta ligands like gabapentin enacarbil can also be effective.
You are about to google βare gabapentin encarbil and gabapentin the same?β
Been there, done that:
11/
Here's a nice table about non-iron pharmacology in RLS:
Here's a nice table about non-iron pharmacology in RLS:
12/
For more about the treatment of RLS (including non-pharmacologic stuff!) and other nocturnal movement disorders, check out this awesome article by Dr. Meena Khan in the Sleep issue of @continuumAAN!
@LyellJ
journals.lww.com
For more about the treatment of RLS (including non-pharmacologic stuff!) and other nocturnal movement disorders, check out this awesome article by Dr. Meena Khan in the Sleep issue of @continuumAAN!
@LyellJ
journals.lww.com
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