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New consensus guidelines for restless leg syndrome (RLS) are out, making it the perfect time to review this common condition.
Top line: these consensus guidelines recommend AGAINST the routine use of dopaminergic meds for treatment.
New consensus guidelines for restless leg syndrome (RLS) are out, making it the perfect time to review this common condition.
Top line: these consensus guidelines recommend AGAINST the routine use of dopaminergic meds for treatment.
RLS is a common condition affecting as many as 10% of the US adult population. Risk factors include iron deficiency, family history, peripheral neuropathy, CKD, and OSA.
Treatment starts with lifestyle factors: address sleep hygiene, screen for OSA, reduce alcohol and caffeine use, encourage daytime exercise.
Med review is also important: SSRIs, 1st gen antihistamines, and anticholinergics are common exacerbators.
Med review is also important: SSRIs, 1st gen antihistamines, and anticholinergics are common exacerbators.
Most of us know to screen for iron deficiency with RLS. But did you know the cutoff values are different than they are for iron deficiency anemia? Thatβs because they are a proxy for CNS iron, not peripheral stores. Use a cutoff of ferritin < 100 ng/mL and iron sat < 20%.
IV iron is often preferred because oral iron is usually ineffective at boosting levels of ferritin much above 50-75.
Okay, now for the big reveal:
Dopamine agonists are no longer recommended in the treatment algorithm routinely.
This is due to the risk of augmentation, or paradoxical worsening of symptoms with prolonged treatment. This occurs in 50%+ of DA-treated patients within 10 years.
Dopamine agonists are no longer recommended in the treatment algorithm routinely.
This is due to the risk of augmentation, or paradoxical worsening of symptoms with prolonged treatment. This occurs in 50%+ of DA-treated patients within 10 years.
DAs may still need to be used in some cases, but it should only come after an honest conversation about the risks with the patient. Itβs a short term gain: long-term use virtually guarantees the disease will eventually become refractory.
First line therapy instead should be with gabapentinoids (gabapentin, pregabalin, gabapentin enacarbil). RCTs have shown equivalent or even superior efficacy of these over DAs, particularly in the long run, and there is no risk of augmentation with the alpha-2-delta ligands.
Second line therapy is with extended-release opioids (oxycodone ER, methadone, buprenorphine). Patients usually respond well to these and require very low doses compared to doses required for chronic pain.
Adjunct treatments include high-frequency fibular nerve stimulation.
Adjunct treatments include high-frequency fibular nerve stimulation.
Takeaway: for neurologists, sleep medicine specialists, and primary care providers alike, itβs time to put away the dopamine agonists.
And for people - like myself - dealing with RLS, there are effective treatments out there!
#neurology #FOAMed #MedEd
And for people - like myself - dealing with RLS, there are effective treatments out there!
#neurology #FOAMed #MedEd
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