51
|
Abstract
Restless legs syndrome (RLS) is a common neurological disorder of unknown etiology that is managed by therapy directed at relieving its symptoms. Treatment of patients with milder symptoms that occur intermittently may be treated with nonpharmacological therapy but when not successful, drug therapy should be chosen based on the timing of the symptoms and the needs of the patient. Patients with moderate to severe RLS typically require daily medication to control their symptoms. Although the dopamine agonists, ropinirole and pramipexole have been the drugs of choice for patients with moderate to severe RLS, drug emergent problems like augmentation may limit their use for long term therapy. Keeping the dopamine agonist dose as low as possible, using longer acting dopamine agonists such as the rotigotine patch and maintaining a high serum ferritin level may help prevent the development of augmentation. The α2δ anticonvulsants may now also be considered as drugs of choice for moderate to severe RLS patients. Opioids should be considered for RLS patients, especially for those who have failed other therapies since they are very effective for severe cases. When monitored appropriately, they can be very safe and durable for long term therapy. They should also be strongly considered for treating patients with augmentation as they are very effective for relieving the worsening symptoms that occur when decreasing or eliminating dopamine agonists.
Collapse
|
52
|
Abstract
While pediatric sleep disorders are relatively common, treatments are often not straightforward. There is often a paucity of gold standard studies and data available to guide clinicians, treatments may yield arguably incomplete results, interventions may require chronic use, and/ or involve multiple modalities including behavioral interventions that require high parental and family commitment. This review points out diagnostic differences compared to adults and focuses on current therapy for selected common pediatric sleep disorders including sleep disordered breathing/ obstructive sleep apnea, narcolepsy, and restless legs syndrome. Other common pediatric sleep disorders, such as insomnia and parasomnias, are not covered.
Collapse
Affiliation(s)
- Shannon S Sullivan
- Department of Psychiatry, Division of Sleep Medicine, Stanford University School of Medicine, Redwood City, CA 94063, USA.
| |
Collapse
|
53
|
Hornyak M, Scholz H, Kiemen A, Kassubek J. Investigating the response to intravenous iron in restless legs syndrome: An observational study. Sleep Med 2012; 13:732-5. [DOI: 10.1016/j.sleep.2012.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 02/03/2012] [Accepted: 02/17/2012] [Indexed: 10/28/2022]
|
54
|
Pedroso JL, Bor-Seng-Shu E, Felicio AC, Braga-Neto P, Dutra LA, de Aquino CC, Ferraz HB, do Prado GF, Teixeira MJ, Barsottini OG. Severity of restless legs syndrome is inversely correlated with echogenicity of the substantia nigra in different neurodegenerative movement disorders. a preliminary observation. J Neurol Sci 2012; 319:59-62. [PMID: 22632781 DOI: 10.1016/j.jns.2012.05.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 05/04/2012] [Accepted: 05/04/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Hyperechogenicity of the substantia nigra is a frequent observation on transcranial sonography in Parkinson's disease and Machado-Joseph disease patients. Additionally, restless legs syndrome is a sleep disorder that is also frequently found in both diseases. Autopsy studies have demonstrated increased SN iron content in hyperechogenic substantia nigra. Iron storage is also known to be involved in restless legs syndrome. We formally compared echogenicity of the substantia nigra with restless legs syndrome in Parkinson's disease and Machado-Joseph disease patients. METHODS Transcranial brain sonography was performed in a sample of Parkinson's disease and Machado-Joseph disease patients, and findings then correlated with the presence and severity of restless legs syndrome. RESULTS There was a continuum of substantia nigra echogenicity among groups (Parkinson's disease versus Machado-Joseph disease versus controls) and sub-groups (Parkinson's disease with and without restless legs syndrome versus Machado-Joseph disease with and without restless legs syndrome) as well as a statistically significant negative correlation between restless legs syndrome severity and substantia nigra echogenicity (p<0.001). CONCLUSIONS These preliminary observations demonstrate that the severity of RLS may be influenced by nigral iron load reflected by substantia nigra echogenicity in different neurodegenerative movement disorders.
Collapse
Affiliation(s)
- José Luiz Pedroso
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
55
|
Abstract
BACKGROUND Restless legs syndrome (RLS) is a common neurologic syndrome and is associated with iron deficiency in many patients. It is unclear whether iron therapy is effective treatment for RLS. OBJECTIVES The objective of this review was to assess the effects of iron supplementation (oral or intravenous) for patients with RLS. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Jan 1995 to April 2011); EMBASE (Jan 1995 to April 2011); PsycINFO (Jan 1995 to April 2011); and CINAHL (Jan 1995 to April 2011). Corresponding authors of included trials and additional members of the International Restless Legs Syndrome Study Group were contacted to locate additional published or unpublished trials. SELECTION CRITERIA Controlled trials comparing any formulation of iron with placebo, other medications, or no treatment in adults diagnosed with RLS according to expert clinical interview or explicit diagnostic criteria. DATA COLLECTION AND ANALYSIS Two review authors extracted data and at least two authors assessed trial quality. We contacted trial authors for missing data. MAIN RESULTS Six studies (192 total subjects) were identified and included in this analysis. The quality of trials was variable. Our primary outcome was restlessness or uncomfortable leg sensations, which was quantified using the IRLS severity scale in four trials and another RLS symptom scale in a fifth trial. Combining data from the four trials using the IRLS severity scale, there was no clear benefit from iron therapy (mean difference in IRLS severity scores of -3.79, 95% CI: -7.68 to 0.10, p = 0.06). However, the fifth trial did find iron therapy to be beneficial (median decrease of 3 points in the iron group and no change in the placebo group on a 10 point scale of RLS symptoms, p = 0.01). Quality of life was improved in the iron group relative to placebo in some studies but not others. Changes in periodic limb movements were not different between groups (measured in two studies). Objective sleep quality, subjective sleep quality and daytime functioning were not different between treatment groups in the studies that assessed them. The single study of subjects with end stage renal disease did show a benefit of therapy. Most trials did not require subjects to have co-morbid iron deficiency and several excluded patients with severe anemia. The single study that was limited to iron deficient subjects did not show clear benefit of iron supplementation on RLS symptoms. There was no clear superiority of oral or intravenous delivery of iron. Iron therapy did not result in significantly more side effects than placebo (RR 1.39, 95% CI 0.85 to 2.27). AUTHORS' CONCLUSIONS There is insufficient evidence to determine whether iron therapy is beneficial for the treatment of RLS. Further research to determine whether some or all types of RLS patients may benefit from iron therapy, as well as the best route of iron administration, is needed.
Collapse
Affiliation(s)
- Lynn M Trotti
- Department of Neurology, Emory University School of Medicine,
Atlanta, USA
| | | | - Lorne A Becker
- Department of Family Medicine, SUNY Upstate Medical University,
Syracuse, NY, USA
| |
Collapse
|
56
|
García-Borreguero D, Högl B, Ferini-Strambi L, Winkelman J, Hill-Zabala C, Asgharian A, Allen R. Systematic evaluation of augmentation during treatment with ropinirole in restless legs syndrome (Willis-Ekbom Disease): Results from a prospective, multicenter study over 66 weeks. Mov Disord 2012; 27:277-83. [DOI: 10.1002/mds.24889] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 10/17/2011] [Accepted: 11/28/2011] [Indexed: 11/10/2022] Open
|
57
|
Allen RP, Ondo WG, Ball E, Calloway MO, Manjunath R, Higbie RL, Lee MR, Nisbet PA. Restless legs syndrome (RLS) augmentation associated with dopamine agonist and levodopa usage in a community sample. Sleep Med 2011; 12:431-9. [DOI: 10.1016/j.sleep.2011.03.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 03/05/2011] [Accepted: 03/09/2011] [Indexed: 10/18/2022]
|
58
|
Högl B, Garcia-Borreguero D, Trenkwalder C, Ferini-Strambi L, Hening W, Poewe W, Brenner SS, Fraessdorf M, Busse M, Albrecht S, Allen RP. Efficacy and augmentation during 6months of double-blind pramipexole for restless legs syndrome. Sleep Med 2011; 12:351-60. [DOI: 10.1016/j.sleep.2010.12.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 12/07/2010] [Accepted: 12/10/2010] [Indexed: 11/17/2022]
|
59
|
Connor JR, Ponnuru P, Wang XS, Patton SM, Allen RP, Earley CJ. Profile of altered brain iron acquisition in restless legs syndrome. Brain 2011; 134:959-68. [PMID: 21398376 DOI: 10.1093/brain/awr012] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Restless legs syndrome is a neurological disorder characterized by an urgency to move the legs during periods of rest. Data from a variety of sources provide a compelling argument that the amount of iron in the brain is lower in individuals with restless legs syndrome compared with neurologically normal individuals. Moreover, a significant percentage of patients with restless legs syndrome are responsive to intravenous iron therapy. The mechanism underlying the decreased iron concentrations in restless legs syndrome brains is unknown. We hypothesize that the source of the brain iron deficit is at the blood-brain interface. Thus we analysed the expression of iron management proteins in the epithelial cells of the choroid plexus and the brain microvasculature in post-mortem tissues. The choroid plexus, obtained at autopsy, from 18 neurologically normal controls and 14 individuals who had primary restless legs syndrome was subjected to histochemical staining for iron and immunostaining for iron management proteins. Iron and heavy chain ferritin staining was reduced in the epithelial cells of choroid plexus in restless legs syndrome. Divalent metal transporter, ferroportin, transferrin and its receptor were upregulated in the choroid plexus in restless legs syndrome. Microvessels were isolated from the motor cortex of 11 restless legs syndrome and 14 control brains obtained at autopsy and quantitative immunoblot analyses was performed. Expression of heavy chain ferritin, transferrin and its receptor in the microvessels from restless legs syndrome was significantly decreased compared with the controls but divalent metal protein 1, ferroportin, prohepcidin, mitochondrial ferritin and light-chain ferritin remained unchanged. The presence of an iron regulatory protein was demonstrated in the brain microvasculature and the activity of this protein is decreased in restless legs syndrome; a finding similar to our earlier report in neuromelanin cells from the substantia nigra of restless legs syndrome brains. This study reveals that there are alterations in the iron management protein profile in restless legs syndrome compared with controls at the site of blood-brain interface suggesting fundamental differences in brain iron acquisition in individuals with restless legs syndrome. Furthermore, the decrease in transferrin receptor expression in the microvasculature in the presence of relative brain iron deficiency reported in restless legs syndrome brains may underlie the problems associated with brain iron acquisition in restless legs syndrome. The consistent finding of loss of iron regulatory protein activity in restless legs syndrome brain tissue further implicates this protein as a factor in the underlying cause of the iron deficiency in the restless legs syndrome brain. The data herein provide evidence for regulation of iron uptake and storage within brain microvessels that challenge the existing paradigm that the blood-brain barrier is merely a transport system.
Collapse
Affiliation(s)
- James R Connor
- Department of Neurosurgery (H110), G.M. Leader Family Laboratory for Alzheimer's Disease Research, Penn State College of Medicine, 500 University Dr., Hershey, PA 17033, USA.
| | | | | | | | | | | |
Collapse
|
60
|
Abstract
PURPOSE OF REVIEW Although restless legs syndrome (RLS) is a disorder recognized in the medical literature since the 17th century, there have only recently been significant clinical and scientific advances in diagnosis, epidemiology and understanding the disorder, mainly due to the advent of dopaminergic treatment. RECENT FINDINGS Recent discoveries have uncovered the iron-dopamine connection in RLS and the basic dopaminergic pathology related to the RLS symptoms. These have led to new understanding of the morbidity of RLS and the many conditions associated with RLS, which have also supported new approaches to treatment. These developments are each briefly described here. SUMMARY Although there has been progress in understanding, diagnosing and treating RLS, it remains an underdiagnosed and undertreated condition severely impairing functioning of patients with moderate-to-severe disease. Much work is needed to improve on current, as well as other novel therapies.
Collapse
|
61
|
Dopamine D3 receptor specifically modulates motor and sensory symptoms in iron-deficient mice. J Neurosci 2011; 31:70-7. [PMID: 21209191 DOI: 10.1523/jneurosci.0959-10.2011] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Restless legs syndrome (RLS) is a common neurological disorder whose exact pathophysiological mechanism remains unclear despite the successful use of dopaminergic treatment and recent discovery of predisposing genetic factors. As iron deficiency has been associated with RLS for some patients and there is evidence for decreased spinal dopamine D(3)-receptor (D3R) signaling in RLS, we aimed at establishing whether D3R activity and iron deficiency share common pathways within the pathophysiology of RLS sensory and motor symptoms. Using a combined mouse model of iron deficiency and dopamine D(3)-receptor deficiency (D3R-/-), circadian motor symptoms were evaluated by continuous recording of spontaneous wheel running activity. Testing the acute and persistent pain responses with the hot-plate test and formalin test, respectively, assessed sensory symptoms. A 15 week iron-deficient (ID) diet alone increased acute and persistent pain responses as compared to control diet. As compared to C57BL/6 (WT), homozygous D3R-/- mice already exhibited elevated responses to acute and persistent pain stimuli, where the latter was further elevated by concurrent iron deficiency. ID changed the circadian activity pattern toward an increased running wheel usage before the resting period, which resembled the RLS symptom of restlessness before sleep. Interestingly, D3R-/- shifted this effect of iron deficiency to a time point 3-4 h earlier. The results confirm the ability of iron deficiency and D3R-/- to evoke sensory and motor symptoms in mice resembling those observed in RLS patients. Furthermore this study suggests an increase of ID-related sensory symptoms and modification of ID-related motor symptoms by D3R-/-.
Collapse
|
62
|
Birgegård G, Schneider K, Ulfberg J. High incidence of iron depletion and restless leg syndrome (RLS) in regular blood donors: intravenous iron sucrose substitution more effective than oral iron. Vox Sang 2011; 99:354-61. [PMID: 20598107 DOI: 10.1111/j.1423-0410.2010.01368.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Iron depletion is common in regular blood donors. The objective of the study was to investigate the frequency and severity of iron depletion in regular blood donors and whether IV iron is more effective than oral to avoid iron depletion and symptoms thereof, especially restless legs syndrome (RLS). METHOD One hundred and twenty blood donors with at least five previous whole blood donations were randomized to receive either IV iron sucrose (Venofer(®), RenaPharma/Vifor, Uppsala, Sweden), 200 mg, or to 20×100 mg of oral iron sulphate (Duroferon(®), GlaxoSmithKline, Stockholm, Sweden), after each blood donation during 1 year. Iron status and RLS incidence and severity were investigated. RESULTS Iron status was generally poor among regular blood donors, especially in women, with a high incidence of iron depletion (>20%) and RLS (18%). The IV iron group increased storage iron to a greater extent than the oral iron group after 12 months (P=0·0043). Female donors were more responsive to IV iron sucrose compared to oral iron sulphate, particularly female donors below 50 years of age. RLS severity scores were significantly lower in the IV iron group. The two treatments were safe. CONCLUSION Iron status is poor in regular blood donors, restless legs syndrome is common, and the routine iron supplementation is insufficient. IV iron sucrose substitutes iron loss in blood donors more efficiently compared with oral iron sulphate, especially in women. Iron substitution to blood donors should be individualized and based on P-ferritin monitoring.
Collapse
Affiliation(s)
- G Birgegård
- Department of Haematology, University Hospital, Uppsala, Sweden.
| | | | | |
Collapse
|
63
|
Abstract
Restless legs syndrome (RLS) is characterized by a compelling, often insatiable, need to move the legs, accompanied by unpleasant sensations located mainly in the ankles and calves. Because symptoms are brought on by inactivity, distress intrudes upon everyday, sedentary activities such as plane travel, car rides, and attending school, meetings, or the theatre. Symptoms show a diurnal preference for the evening and night, so disruption of sleep onset or maintenance is particularly common. RLS is associated with both lower ratings of quality of life and higher rates of cardiovascular disease. Four common genetic loci associating to RLS have recently been identified, but the molecular pathways by which they increase risk for RLS have yet to be determined. Both sensory (RLS) and motor (periodic limb movements of sleep) symptoms are responsive to dopaminergic medications, yet clear delineation of dopaminergic pathology has not emerged. Brain iron is reduced in many, but not all, patients with RLS. First-line treatment for RLS includes agents acting at D(2) and D(3) dopamine receptors.
Collapse
|
64
|
Deak MC, Winkelman JW. The Pharmacologic Management of Restless Legs Syndrome and Periodic Leg Movement Disorder. Sleep Med Clin 2010. [DOI: 10.1016/j.jsmc.2010.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
65
|
Benediktsdottir B, Janson C, Lindberg E, Arnardóttir ES, Olafsson I, Cook E, Thorarinsdottir EH, Gislason T. Prevalence of restless legs syndrome among adults in Iceland and Sweden: Lung function, comorbidity, ferritin, biomarkers and quality of life. Sleep Med 2010; 11:1043-8. [DOI: 10.1016/j.sleep.2010.08.006] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 08/23/2010] [Indexed: 10/18/2022]
|
66
|
Garcia-Borreguero D, Allen R, Kohnen R, Benes H, Winkelman J, Högl B, Ferini-Strambi L, Zucconi M, Trenkwalder C. Loss of response during long-term treatment of restless legs syndrome: guidelines approved by the International Restless Legs Syndrome Study Group for use in clinical trials. Sleep Med 2010; 11:956-7. [PMID: 20817602 DOI: 10.1016/j.sleep.2010.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 08/03/2010] [Indexed: 11/26/2022]
|
67
|
Restless legs syndrome: Understanding its consequences and the need for better treatment. Sleep Med 2010; 11:807-15. [DOI: 10.1016/j.sleep.2010.07.007] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 07/26/2010] [Accepted: 07/29/2010] [Indexed: 11/21/2022]
|
68
|
Advances in pediatric restless legs syndrome: Iron, genetics, diagnosis and treatment. Sleep Med 2010; 11:643-51. [DOI: 10.1016/j.sleep.2009.11.014] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 11/12/2009] [Accepted: 11/18/2009] [Indexed: 11/22/2022]
|
69
|
Trenkwalder C, Paulus W. Restless legs syndrome: pathophysiology, clinical presentation and management. Nat Rev Neurol 2010; 6:337-46. [PMID: 20531433 DOI: 10.1038/nrneurol.2010.55] [Citation(s) in RCA: 200] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
70
|
García-Borreguero D, Williams AM. Dopaminergic augmentation of restless legs syndrome. Sleep Med Rev 2010; 14:339-46. [PMID: 20219397 DOI: 10.1016/j.smrv.2009.11.006] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 11/29/2009] [Accepted: 11/30/2009] [Indexed: 11/24/2022]
Abstract
Dopaminergic agents are the first-line treatment of restless legs syndrome (RLS), and have been used for the treatment of this disorder since the 1980s. The major issue with this class of drugs is augmentation of RLS symptoms during treatment. The first report of augmentation found an occurrence among 73% of patients treated with levodopa. Subsequent studies have reported somewhat lower incidences, but augmentation remains a clinically significant issue with all dopaminergic agents. It was not until 2007 that an operational, empirical definition of augmentation (Max Planck Institute Criteria) was made. This late development and the fact that studies have not been specifically designed to assess augmentation, have made it particularly difficult to compare the incidence rates for the different RLS treatments. As the primary neural and molecular substrates underlying idiopathic RLS are not known, the pathophysiology of augmentation remains unclear, however there are several hypotheses that concern the role of dopaminergic hyperstimulation, of iron deficiency, the genetic component, the effect of a reduction in responsiveness of tubero-infundibular dopamine receptors, and the role of chronobiotic mechanisms. RLS is treated by maintaining low doses of dopaminergic agents and ensuring iron sufficiency. Non-dopaminergics and opiates can be used when patients experience augmentation with more than one dopaminergic agent.
Collapse
|
71
|
Sixel-Döring F, Trenkwalder C. Rotigotine transdermal delivery for the treatment of restless legs syndrome. Expert Opin Pharmacother 2010; 11:649-56. [DOI: 10.1517/14656561003621257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
72
|
Facheris MF, Hicks AA, Pramstaller PP, Pichler I. Update on the management of restless legs syndrome: existing and emerging treatment options. Nat Sci Sleep 2010; 2:199-212. [PMID: 23616710 PMCID: PMC3630948 DOI: 10.2147/nss.s6946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Restless legs syndrome (RLS) is a sensorimotor disorder, characterized by a circadian variation of symptoms involving an urge to move the limbs (usually the legs) as well as paresthesias. There is a primary (familial) and a secondary (acquired) form, which affects a wide variety of individuals, such as pregnant women, patients with end-stage renal disease, iron deficiency, rheumatic disease, and persons taking medications. The symptoms reflect a circadian fluctuation of dopamine in the substantia nigra. RLS patients have lower dopamine and iron levels in the substantia nigra and respond to both dopaminergic therapy and iron administration. Iron, as a cofactor of dopamine production and a regulator of the expression of dopamine type 2-receptor, has an important role in the RLS etiology. In the management of the disease, the first step is to investigate possible secondary causes and their treatment. Dopaminergic agents are considered as the first-line therapy for moderate to severe RLS. If dopaminergic drugs are contraindicated or not efficacious, or if symptoms are resistant and unremitting, gabapentin or other antiepileptic agents, benzodiazepines, or opioids can be used for RLS therapy. Undiagnosed, wrongly diagnosed, and untreated RLS is associated with a significant impairment of the quality of life.
Collapse
Affiliation(s)
- Maurizio F Facheris
- Institute of Genetic Medicine, European Academy Bozen/Bolzano (EURAC), Bolzano, Italy (Affiliated institute of the University of Lübeck, Lübeck, Germany) ; Department of Neurology, Central Hospital, Bolzano, Italy
| | | | | | | |
Collapse
|
73
|
Abstract
Restless legs syndrome (RLS) is a common neurological sensory-motor disorder that is characterized by intense restlessness and unpleasant creeping sensations deep inside the lower legs. Symptoms appear when the legs are at rest and are worst in the evening and at night. They force patients to keep moving their legs, and often to get out of bed and wander about. Periodic limb movements (PLMS) are also common during sleep amongst those suffering from RLS, and sleep efficiency is severely reduced. There are idiopathic as well as symptomatic forms of RLS, the latter being associated with e.g. pregnancy, iron deficiency and chronic renal failure. A family history of RLS is very common and pedigrees in these cases suggest an autosomal-dominant transmission with high penetrance. Genetic investigations have been performed in order to identify genes associated with RLS. Several loci have been found (on chromosomes 12q, 14q, 9p, 2q, 20p and 16p). Pathophysiology of RLS remains incompletely understood. However, advanced brain imaging studies and positive results of dopaminergic treatment suggest that RLS may be generated by dopamine dysfunction locally within the central nervous system. At present, there is a wide range of treatment options including levodopa, dopamine agonists, opioids, benzodiazepines, antiepileptic drugs and iron supplements.
Collapse
Affiliation(s)
- Karl Ekbom
- Department of Neurology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sleep Disorders Center, Avesta Hospital, Stockholm, Sweden.
| | | |
Collapse
|
74
|
Progressive development of augmentation during long-term treatment with levodopa in restless legs syndrome: results of a prospective multi-center study. J Neurol 2009; 257:230-7. [PMID: 19756826 PMCID: PMC3085743 DOI: 10.1007/s00415-009-5299-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 07/29/2009] [Accepted: 08/14/2009] [Indexed: 10/26/2022]
Abstract
The European Restless Legs Syndrome (RLS) Study Group performed the first multi-center, long-term study systematically evaluating RLS augmentation under levodopa treatment. This prospective, open-label 6-month study was conducted in six European countries and included 65 patients (85% treatment naive) with idiopathic RLS. Levodopa was flexibly up-titrated to a maximum dose of 600 mg/day. Presence of augmentation was diagnosed independently by two international experts using established criteria. In addition to the augmentation severity rating scale (ASRS), changes in RLS severity (International RLS severity rating scale (IRLS), clinical global impression (CGI)) were analyzed. Sixty patients provided evaluable data, 35 completed the trial and 25 dropped out. Augmentation occurred in 60% (36/60) of patients, causing 11.7% (7/60) to drop out. Median time to occurrence of augmentation was 71 days. The mean maximum dose of levodopa was 311 mg/day (SD: 105). Patients with augmentation compared to those without were significantly more likely to be on higher doses of levodopa (> or =300 mg, 83 vs. 54%, P = 0.03) and to show less improvement of symptom severity (IRLS, P = 0.039). Augmentation was common with levodopa, but could be tolerated by most patients during this 6-month trial. Patients should be followed over longer periods to determine if dropout rates increase with time.
Collapse
|
75
|
|
76
|
Recent advances in the diagnosis, genetics and treatment of restless legs syndrome. J Neurol 2009; 256:539-53. [DOI: 10.1007/s00415-009-0134-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Accepted: 10/27/2008] [Indexed: 01/08/2023]
|
77
|
Abstract
Sleep disorders are common and may result in significant morbidity. Examples of the major sleep disturbances in primary care practice include insomnia; sleep-disordered breathing, such as obstructive sleep apnea; central nervous system hypersomnias, including narcolepsy; circadian rhythm sleep disturbances; parasomnias, such as REM sleep behavior disorder; and sleep-related movement disorders, including restless legs syndrome. Diagnosis is based on meticulous inventory of the clinical history and careful physical examination. In some cases referral to a sleep laboratory for further evaluation with polysomnography, a sleep study, is indicated.
Collapse
Affiliation(s)
- Lori A Panossian
- UCLA Department of Neurology, UCLA Medical Center, Los Angeles, CA 90095-1767, USA
| | | |
Collapse
|
78
|
Frauscher B, Gschliesser V, Brandauer E, El-Demerdash E, Kaneider M, Rücker L, Poewe W, Högl B. The severity range of restless legs syndrome (RLS) and augmentation in a prospective patient cohort: association with ferritin levels. Sleep Med 2009; 10:611-5. [PMID: 19200780 DOI: 10.1016/j.sleep.2008.09.007] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2008] [Revised: 09/11/2008] [Accepted: 09/12/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of the study was to prospectively examine all patients with a diagnosis of RLS consulting a sleep disorders clinic and to assess RLS severity and augmentation and their associations, including ferritin levels. METHODS Patients were stratified into patients with RLS as ancillary diagnosis, RLS sufferers without current augmentation and RLS sufferers with current augmentation. Work-up included RLS severity scales and blood biochemical variables including indices of iron metabolism. RESULTS In an 18-month period, 302 patients with RLS (183 women, 119 men; mean age, 59.1+/-13.7 years) were recruited. RLS was considered idiopathic in 291 patients (96.4%). Most patients (240, 79.5%) were RLS sufferers, whereas the remaining 62 (20.5%) had RLS as ancillary diagnosis. Nineteen out of 162 patients treated with dopaminergic agents (11.7%) had current augmentation. Almost one-third of all patients (31.1%) had ferritin levels <50microg/l. Patients with an ancillary diagnosis of RLS had higher ferritin levels than RLS sufferers without current augmentation. The lowest ferritin levels were present in RLS sufferers with current augmentation 132.8+/-98.0microg/l vs. 100.6+/-84.5microg/l vs. 55.8+/-43.6microg/l; p=0.002). Patients with augmentation did not differ from non-augmented patients regarding age, gender, RLS etiology, presence of previous augmentation, or any other documented comorbidity (p>0.05). CONCLUSION The severity spectrum of RLS in this clinical cohort ranged from the ancillary diagnosis of RLS to augmented RLS. There was an inverse correlation between RLS severity and ferritin levels. Patients with current augmentation had the lowest ferritin levels. Our data further strengthen a putative role of low iron stores as a potential aggravator of idiopathic RLS. Moreover, low ferritin might represent a potential biomarker of RLS augmentation under dopaminergic therapy.
Collapse
Affiliation(s)
- Birgit Frauscher
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
| | | | | | | | | | | | | | | |
Collapse
|
79
|
Simakajornboon N, Kheirandish-Gozal L, Gozal D. Diagnosis and management of restless legs syndrome in children. Sleep Med Rev 2009; 13:149-56. [PMID: 19186083 DOI: 10.1016/j.smrv.2008.12.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 12/02/2008] [Accepted: 12/02/2008] [Indexed: 10/21/2022]
Abstract
Recent published evidence suggests that restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are common condition in children and adolescents. It is likely that if left untreated, RLS and PLMD may lead to adverse cardiovascular and neurocognitive consequences. However, the diagnosis of RLS and PLMD in children is challenging, particularly because children are relatively unable to describe typical RLS symptoms. The International Restless Legs Study Group has recently published consensus criteria for the diagnosis of RLS and PLMD in children. In addition to clinical description of RLS symptoms, supportive evidence including the presence of clinical sleep disturbances, documented periodic limb movements in sleep from overnight sleep study and family history of restless legs syndrome may be required. Few if any controlled studies have addressed the management of RLS and PLMD, which may involve both non-pharmacologic and pharmacologic approaches. In this context, the importance of avoidance of aggravating factors and good sleep hygiene cannot be overemphasized. Children with evidence of low-iron storage, i.e., low-serum ferritin and/or iron levels may likely benefit from iron therapy. While there is overall limited experience regarding the use of dopaminergic agents in children with RLS and PLMD, published reports suggesting efficacy of compounds such as levodopa, ropinirole, pramipexole and pergolide have emerged. Other medications including benzodiazepine, anti-convulsants, alpha-adrenergic and opioid medications have not been adequately studied in children. Children with RLS and PLMD should have regular follow-up visits to evaluate clinical improvement and to monitor adverse effects from the selected therapy. Based on aforementioned findings, it is clear that a substantial research effort is needed to evaluate the pathophysiology, clinical presentation, treatment modalities, and overall long-term outcome of children with RLS and PLMD.
Collapse
|
80
|
Trenkwalder C, Hening WA, Montagna P, Oertel WH, Allen RP, Walters AS, Costa J, Stiasny-Kolster K, Sampaio C. Treatment of restless legs syndrome: An evidence-based review and implications for clinical practice. Mov Disord 2008; 23:2267-302. [PMID: 18925578 DOI: 10.1002/mds.22254] [Citation(s) in RCA: 201] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Claudia Trenkwalder
- Paracelsus-Elena Hospital, Center of Parkinsonism and Movement Disorders, Kassel, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
81
|
Connor JR. Pathophysiology of restless legs syndrome: evidence for iron involvement. Curr Neurol Neurosci Rep 2008; 8:162-6. [PMID: 18460286 DOI: 10.1007/s11910-008-0026-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Neuroimaging, analysis of cerebrospinal fluid, and studies on postmortem tissue are generating data that support the concept that iron availability to the brain is a contributory process to, if not a cause of, restless legs syndrome. These data are reviewed and related to the dopaminergic system because of the use of dopamine agents in treating restless legs syndrome.
Collapse
Affiliation(s)
- James R Connor
- G.M. Leader Family Laboratory, Department of Neurosurgery, Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Drive, PO Box 850, Hershey, PA 17033, USA.
| |
Collapse
|
82
|
Karroum E, Konofal E, Arnulf I. [Restless-legs syndrome]. Rev Neurol (Paris) 2008; 164:701-21. [PMID: 18656214 DOI: 10.1016/j.neurol.2008.06.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Revised: 04/10/2008] [Accepted: 06/06/2008] [Indexed: 11/26/2022]
Abstract
Restless-legs syndrome (RLS) is a sensorimotor disorder, characterized by an irresistible urge to move the legs usually accompanied or caused by uncomfortable and unpleasant sensations. It begins or worsens during periods of rest or inactivity, is partially or totally relieved by movements and is exacerbated or occurs at night and in the evening. RLS sufferers represent 2 to 3% of the general population in Western countries. Supportive criteria include a family history, the presence of periodic-leg movements (PLM) when awake or asleep and a positive response to dopaminergic treatment. The RLS phenotypes include an early onset form, usually idiopathic with a familial history and a late onset form, usually secondary to peripheral neuropathy. Recently, an atypical RLS phenotype without PLM and l-DOPA resistant has been characterized. RLS can occur in childhood and should be distinguished from attention deficit/hyperactivity disorder, growing pains and sleep complaints in childhood. RLS should be included in the diagnosis of all patients consulting for sleep complaints or discomfort in the lower limbs. It should be differentiated from akathisia, that is, an urge to move the whole body without uncomfortable sensations. Polysomnographic studies and the suggested immobilization test can detect PLM. Furthermore, an l-DOPA challenge has recently been validated to support the diagnosis of RLS. RLS may cause severe-sleep disturbances, poor quality of life, depressive and anxious symptoms and may be a risk factor for cardiovascular disease. In most cases, RLS is idiopathic. It may also be secondary to iron deficiency, end-stage renal disease, pregnancy, peripheral neuropathy and drugs, such as antipsychotics and antidepressants. The small-fiber neuropathy can mimic RLS or even trigger it. RLS is associated with many neurological and sleep disorders including Parkinson's disease, but does not predispose to these diseases. The pathophysiology of RLS includes an altered brain-iron metabolism, a dopaminergic dysfunction, a probable role of pain control systems and a genetic susceptibility with nine loci and three polymorphisms in genes serving developmental functions. RLS treatment begins with the elimination of triggering factors and iron supplementation when deficient. Mild or intermittent RLS is usually treated with low doses of l-DOPA or codeine; the first-line treatment for moderate to severe RLS is dopaminergic agonists (pramipexole, ropinirole, rotigotine). In severe, refractory or neuropathy-associated RLS, antiepileptic (gabapentin, pregabalin) or opioid (oxycodone, tramadol) drugs can be used.
Collapse
Affiliation(s)
- E Karroum
- UF pathologies du sommeil, groupe hospitalier Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, pavillon Marguerite-Bottard, Paris cedex, France.
| | | | | |
Collapse
|