Transcript Restless Leg Syndrome - Swindon GP Education

Restless Leg Syndrome
•“The most common
disorder you have
never heard of.”
What are Restless legs?
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Neurological movement disorder
Irresistible urge to move legs when at
rest
Difficulty sleeping
Involuntary periodic leg movements
Uncomfortable sensation in limbs
subjective & difficult to describe
Symptoms eased by movement
Why should we know about it?
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Excess 5 million in UK are sufferers (MEMO
2000)
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Estimated prevalence 2-15%
Sufferers will present to primary care
Important physical cause of sleep
disturbance
Clinical diagnosis which can be made in
primary care
Why should we know about it?
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Unrecognised & under-diagnosed
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Incorrectly labeled as stress / anxiety
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Managed poorly
Wide spectrum
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Affects any age group
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Mild
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More common in middle age + women
Minimal distress
Severe
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Episodes occur >2 per week
Can be disabling
Why is it important?
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Large impact on quality of life: (REST Study)
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Poor sleep
Inability to get comfortable / relax
Poor concentration / fatigue
Pain
Depression
Problems in day to day functioning / employment
Implications for partner
Common descriptive terms
used by patients
How do we diagnosis RLS?
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International Restless Legs Syndrome
Study Group - 2003
Supporting Features
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Positive FHx (50-92%)
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Involuntary limb movements (80%)
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Sleep disturbance
What investigations should we
do?
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Exclude secondary cause.
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Examination
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Vascular dx / Neuropathy / nocturnal cramp
/ anxiety
Neuro / vascular
Bloods
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FBC, ferritin, B12, Folate, U&E, Glucose,
TFT
Aetiology
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Primary
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No underlying cause found.
Positive FHx >50%
Earlier onset / slower progression
Secondary
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Fe deficiency
Pregnancy
End stage renal disease
Peripheral neuropathy / DM / RA / Fibromyalgia
Later onset / more severe
Pathophysiology
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Genetic
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Susceptibility loci identified on 3
chromosomes
Positive FHx >50%
Neurochemical
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Dopaminergic dysfunction - universal
response to dopaminergic agents
Ferritin level - inverse relation between
severity and serum ferritin
What are the treatment
options?
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Non Pharmacological
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Preventative measures
Symptomatic control
Pharmacological
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PRN treatment - mild / intermittent
Maintenance treatment - moderate / severe
Majority of treatments used ‘off license’
Non pharmacological
treatment
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Preventative
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Avoid caffeine / alcohol / nicotine
Avoid medication which may aggravate
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SSRI / antihistamine / antiemetic / CaChannel blockers
Keep active into evening
Good sleep hygiene
Symptom control
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Mental alerting activities
Walking / stretching
Massage
Hot / cold bath
Relaxation / biofeedback
Pharmacological options
Drug
Advantage
Disadvantage
Iron
Helpful if serum
ferritin low
Slow response
Dopamine
agonist
Pramipexole /
ropinirole
High efficacy
(70-100%)
Less
augmentation
Daytime
sleepiness
Long term effect
not known
Dopaminergic
agent
Carbidopa /
levodopa
Can be used
PRN basis
Shown to be
effective
Up to 80%
develop
augmentation
Pharmacological options
Drug
Advantage
Disadvantage
Anticonvulsants Useful in
Gabapentin /
neuropathy /
Carbamazepine associated pain
Side effect profile
Benzos
PRN use + help
sleep
Cognitive
impairment,
dependence
Opioids
PRN use /
daytime use
Cognitive
impairment,
dependence
Rx Flow chart - RLS:UK
Mirapexin (pramipexole)
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First drug treatment / ONLY treatment
licensed in EU for RLS
For use in moderate / severe disease
Quick onset of symptom relief (<1/52)
Start low dose 125mcg od
Titrate up (max 750mcg od)
What should we be doing?
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Have raised awareness about diagnosis
Exclude / treat secondary causes
Symptoms generally mild + reassurance
& non-pharmacological measures
suffice
In moderate / severe cases consider
onward referral
Useful Info
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Resources
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www.ekbom.org.uk
www.restlesslegs.org.uk
www.restlesslegs.com
Review
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DTB Nov 2003
Bandolier 118