I’ve received numerous messages in response to my recent restless leg syndrome (RLS) post, some of which asked about treatments. So let’s address that now, shall we?
One important thing to know, first of all, is that not all cases of RLS require treatment. Like most other medical disorders, there is a spectrum of severity with RLS; mild cases, only slightly annoying or easily made better with a brief walk up and down the hall, may not need medications. Me, I consider treating RLS patients whose qualities of life are compromised by the problem: difficulties participating in activities; ongoing difficulties falling and/or staying asleep; chronic discomfort; bed partners unable to sleep because of the movements.
Typically I first explore if an RLS sufferer has iron deficiency. Iron deficiency is quite common; it’s estimated that 1/3 of iron-deficient people have RLS. 20% of RLS sufferers have iron deficiency. There’s a lot that is still not understood about exactly what causes RLS, but it appears that RLS is related to dysfunction associated with a specific neurotransmitter called dopamine. Iron is a mineral co-factor associated with the production of dopamine in your brain. I check a serum ferritin level when assessing an RLS patient. Ferritin is an iron storage protein. It’s known in the medical literature that ferritin levels of 50 or less are associated with an increased propensity to having RLS. Iron supplementation (such as with ferrous sulfate or ferrous gluconate) thus may be very helpful in improving RLS symptoms.
For those with RLS of unknown cause, here are the FDA-approved medications to treat RLS symptoms:
1. Ropinerole (Requip). This is a dopamine agonist, which means it activates dopamine receptors in your brain. You take it by mouth. This medication is the first FDA-approved medication for RLS treatment. It’s available generically now, which means the potential for cost-savings.
2. Pramipexole (Mirapex). This is also an oral dopamine agonist medication, available generically.
3. Gabapentin enacarbil (Horizant). This is an extended-release tablet that you take once per day, around 5 p.m. Unique features: it’s not a dopamine agonist (it is the pro-drug to gabapentin); and it’s long-acting.
4. Rotigotine Transdermal System (Neupro). This is also a dopamine agonist medication, but the unique feature here is that it comes in a patch, which you apply once each day to the skin.
My practice is to use the minimal medication that provides the maximal effect in stopping the RLS symptoms. The orally-dose dopamine agonist medications typically are taken in the evening. I generally recommend that the medication be taken roughly 1-2 hours prior to the projected onset of symptoms; it’s better to try to prevent the symptoms from happening than to try to tamp the symptoms down once they’ve started.
Other medications have historically been used, including benzodiazepines, sedative agents, and, particularly in the case of severe, difficult-to-treat RLS, narcotics. Non-medicinal treatments used over the years are legion, and include mild to moderate exercise prior to bedtime and hot baths or compresses prior to bedtime. Avoiding caffeine and alcohol use in the evening may also be helpful; I recently had a patient whose RLS completely went away by stopping her late afternoon caffeine consumption.
No medication is perfect or without side effects. Dopamine agonists can be associated with daytime sleepiness in some, but so can Horizant. In addition, there is the potential for something called augmentation (a gradual worsening of symptoms due to or related to ongoing treatment), which may occur particularly in the setting of dopamine agonist use. As always, you need to weigh benefits and risks when considering treatment, and you should have a clear, open discussion with your doctor regarding the nature and severity of your symptoms, as well as longterm management of the RLS.
I will post some fun sleep topics in the coming days. Thanks, everybody!