Transcript Restless Legs Syndrome

Restless Legs Syndrome:
Classification, Diagnosis and
Approaches to Treatment
Part 3 of 3
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RLS Slide Library Version 1.0 - All Contents Copyright © WE MOVE 2001
RLS Treatment Goals
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Eliminate or minimize associated symptoms
Reduce EDS
Improve overall quality of life
Improve activities of daily living
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Overall Treatments
• Nonpharmacologic
• Pharmacological
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Possible Underlying Disorders
• Anemia
• Folic acid deficiency
• End-stage renal disease
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Potential Aggravators of RLS
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Tobacco products
Alcohol
Caffeine
Certain medications
Sleep deprivation
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Potentially Beneficial Strategies
• Maintaining a regular sleep regimen
• Sleeping late in the circadian cycle
• Undertaking regular, moderate exercise
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Additional Approaches
• Tasks that engage the mind during sedentary
periods
• Bedtime massages
• Hot baths
• Cold packs or hot compresses
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Scope of RLS Treatment
• Established therapies are pharmacologic
• No known cure
• Therapy directed at symptomatic relief
and improved ADLs and QOL
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Start Treatment
Initiation of Drug Therapy
• Review medical history and current drug
regimen
• Use single drug, when possible, for
comorbidities
• PRN meds for episodic RLS
• Use minimal effective dose
• Treatment during early evening hours
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Dopaminergic Agents:
First-line RLS Therapies
• Dopamine agonists (DAs)
• Dopamine precursors (levodopa)
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Dopamine Agonists (DAs)
Capable of alleviating all major
symptoms of RLS
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Bromocriptine
Pergolide
Pramipexole
Ropinerole
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Dopamine Precursors
Carbidopa/levodopa available as…
• Sinemet® in 10/100, 25/100, or 25/250
• Sinemet®CR in 25/100, 50/200
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Administration of Levodopa for RLS
• PRN or on a regular schedule
• One to 2 hours before bedtime
• On an empty stomach, if possible
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Dosage of Carbidopa/levodopa for RLS
• Initially 12.5/50 mg/day to 25/100 mg/day
of regular formulation for symptoms for
waking with symptoms at night
• 25/100 mg/day of controlled-release
formulation useful at bedtime/sleep onset
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Higher Doses of Levodopa
• Increased risk of augmentation
• Worsening of symptoms
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Adverse Effects of Levodopa
• GI symptoms: nausea and vomiting,
constipation or diarrhea, anorexia
• Sleep disturbances: insomnia, fatigue
• Other: anxiety, dry mouth, flushing,
headache
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Dopamine Agonists (DAs)
• Ergotolines
– Pergolide (Permax®)
– Bromocriptine (Parlodel®)
• Nonergotolines
– Pramipexole (Mirapex®)
– Ropinirole (Requip™)
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Ergot Derivatives
• Pergolide (Permax®)
• Bromocriptine (Parlodel®)
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Pergolide Therapy for RLS
• Long-acting
• Higher relative potency than bromocriptine
• Well-absorbed through GI tract
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Initiation of DA Therapy
• Relatively small dosage
– 0.05 mg for pergolide
– 1.25-2.50 mg for bromocriptine
• Slow titration upward
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Advantages of Pergolide or
Bromocriptine
• Less augmentation than with
carbidopa/levodopa
• First-line therapy for patient with moderate
or severe RLS
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Adverse Effects Specific to
Pergolide and Bromocriptine
• Contraindication: known hypersensitivity
to ergot alkaloids
• Rare complications:
– Pulmonary or retroperitoneal fibrosis
– Pleural thickening and effusions
• Reddened, edematous skin changes in legs
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Nonergotoline DAs for RLS
• Pramipexole (Mirapex®)
• Ropinirole (Requip®)
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Pramipexole Targets:
Several RLS Symptoms
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Key Benefits of Nonergotoline DAs
• Possible effectiveness in non-responders
to other DAs (i.e., ergotolines)
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Initiating Pramipexole Therapy for RLS
• Initiate with low dose of 0.125 mg/day
or lower
• Gradual titration to therapeutic range
of 0.25 mg to 1.5 mg/day
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Adverse Effects of DAs
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Nausea/vomiting
Orthostatic hypertension
Nasal congestion
Insomnia
Dizziness
Lightheadedness
Somnolence
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Other Drugs with Dopaminergic Action
• Amantadine (Symmetrel®)
• Selegiline (Eldepryl®)
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Benzodiazepines for RLS
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Clonazepam (Klonopin®)
Temazepam (Restoril®)
Diazepam (Valium®)
Triazolam (Halcion®)
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Benzodiazepine Issues for RLS
• Schedule C-IV controlled substances
• Low risk of tolerance/abuse
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Role of Benzodiazepines in RLS
• May be combined with dopamine agonists
or carbidopa/levodopa
• Most benefit
– Mild and intermittent symptoms
– Young patients
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Daily Doses of Benzodiazepines for RLS
• Clonazepam: 0.75 mg
• Diazepam: 2.0 to 5.0 mg
• Triazolam: 0.125 to 0.25 mg
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AEs of Benzodiazepines
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Daytime somnolence
“Hang over”
Decreased libido
Risk of falls
Exacerbation of pre-existing sleep apnea
Tolerance and dependency
Withdrawal symptoms
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Opioids in the Treatment of RLS
• Propoxyphene hydrochloride (Darvon®)
• Codeine
• Oxycodone hydrochloride
(Percocet® or Roxicodone®)
• Methadone hydrochloride
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Administration of Opioids For RLS
• Oral administration
• Taken with food to minimize GI upset
• Taken at bedtime
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Adverse Effects of Opioids
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Nausea
Constipation
Mental changes
Interaction with other CNS depressants
Addiction
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Other Pharmacologic Agents for RLS
• Anticonvulsants
– Carbamazepine (Tegretol®)
– Gabapentin (Neurontin®)
• Antihypertensives
– Clonidine hydrochloride (Catapres®)
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Other Pharmacologic Agents for RLS
• Antispasticity agents
– Baclofen
• Mixed analgesics and sedative-hypnotics
– Tramadol (Ultram®)
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