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Costales B, Vouri SM, Brown JD, Setlow B, Goodin AJ. Risk of Suicidal Ideation and Behavior Following Early-Onset Idiopathic Restless Legs Syndrome Treatment. Pharmacoepidemiol Drug Saf 2024; 33:e5852. [PMID: 39099262 PMCID: PMC11309576 DOI: 10.1002/pds.5852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/15/2024] [Accepted: 05/28/2024] [Indexed: 08/06/2024]
Abstract
PURPOSE To estimate incidence rates of suicidal ideation and behavior following treatment initiation with gabapentinoids or dopamine agonists (DAs) in patients with newly diagnosed early-onset idiopathic restless legs syndrome (RLS) and to examine suicidal behavior risk, comparing between those receiving gabapentinoids and DAs. METHODS A new user retrospective cohort study using MarketScan claims data from 2012 to 2019 was conducted. Exposures were monotherapy gabapentinoids or DAs initiated within 60 days of new RLS diagnosis. Three varying outcome measures of suicidality were examined and incidence rates were calculated for each. A log-binomial regression model the estimated relative risk (RR) of the outcomes with gabapentinoids. Propensity score weighting adjusted for baseline covariates, including age, substance use disorders, hyperlipidemia, antipsychotic use, hypnotic/sedative use, and mood stabilizer use, which were most imbalanced before weighting. RESULTS The cohort included 6672 patients, with 4986 (74.7%) initiating a DA and 1686 (25.3%) initiating a gabapentinoid. Incidence rates for all outcome measures were higher in the gabapentinoid group (suicidality: 21.6 vs. 10.7 per 1000 person-years; suicidality with self-harm: 23.0 vs. 11.1 per 1000 person-years; overdose- and suicide-related events: 30.0 vs. 15.5 person-years). Associated risk of suicidality (adjusted RR, 1.27 [95% CI, 0.86-1.88]); suicidality with self-harm (adjusted RR, 1.30 [95% CI, 0.89-1.90]); or overdose- and suicide-related events (adjusted RR, 1.30 [95% CI, 0.93-1.80]) was not significant with gabapentinoids. CONCLUSIONS Incidence rates for suicidal ideation and behavior were higher among the gabapentinoid group, although increased risk was not detected after adjustment. A possible signal cannot be ruled out given limitations of the data and rarity of the outcome.
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Affiliation(s)
- Brianna Costales
- Department of Pharmaceutical Outcomes & Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA
- Center for Drug Evaluation & Safety, Department of Pharmaceutical Outcomes & Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Scott M. Vouri
- Department of Pharmaceutical Outcomes & Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA
- Center for Drug Evaluation & Safety, Department of Pharmaceutical Outcomes & Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Joshua D. Brown
- Department of Pharmaceutical Outcomes & Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA
- Center for Drug Evaluation & Safety, Department of Pharmaceutical Outcomes & Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Barry Setlow
- Department of Psychiatry, University of Florida, College of Medicine, Gainesville, FL, USA
| | - Amie J. Goodin
- Department of Pharmaceutical Outcomes & Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA
- Center for Drug Evaluation & Safety, Department of Pharmaceutical Outcomes & Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA
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Butt NI, Ghoauri MSA, Waris U, Sabeh D, Qaisar F. Frequency of Restless Legs Syndrome in Pakistani Patients With Type 2 Diabetes Mellitus. Cureus 2024; 16:e62624. [PMID: 39027768 PMCID: PMC11257648 DOI: 10.7759/cureus.62624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/20/2024] Open
Abstract
Objective To determine the frequency of restless legs syndrome (RLS) among Pakistani patients with type 2 diabetes mellitus. Methods This observational cross-sectional study was carried out in the Department of Medicine at Bahawal Victoria Hospital, Quaid-e-Azam Medical College, Bahawalpur, Pakistan, from January 2024 to May 2024. The National Institute of Health (NIH) diagnostic criteria were used to diagnose RLS. Type 2 diabetes mellitus was defined as patients with an HbA1c greater than 7.0%, two random blood glucose readings of ≥200 mg/dL, a previous history of diabetes diagnosis, or those taking anti-hyperglycemic medicines. Patients with a history of leg surgery or amputation, iron deficiency anemia, alcoholism, end-stage kidney disease, chronic liver disease, those on hemodialysis, and pregnant women were excluded from the study. After ethical approval and informed consent were obtained, 255 patients with type 2 diabetes mellitus were included in the study using a non-probability consecutive sampling technique. Demographic information including age, gender, and duration of diabetes was noted, and patients were assessed for diabetes control, peripheral neuropathy, retinopathy, and RLS Patient records were assessed for HbA1c levels and urine examination to diagnose nephropathy. All data were entered into SPSS version 23. A Chi-Square test was applied post-stratification using a p-value of less than 0.05 as significant. Results The mean age was 53.5 ± 12.8 years with 140 (54.9%) females. The mean duration of the disease and mean HbA1c were 6.8 ± 5.4 years and 9.8 ± 2.5%, respectively, with 191 (74.9%) patients having poor control of diabetes. Peripheral neuropathy was seen in 131 (51.4%) patients, retinopathy in 58 (22.7%), and nephropathy in 23 (9.0%). RLS was present in 34 (13.3%) patients with type 2 diabetes mellitus, showing a significant association with diabetes control (p-value = 0.001), peripheral neuropathy (p-value = 0.016), retinopathy (p-value = 0.006), and nephropathy (p-value = 0.011), but not with age (p-value = 0.122), gender (p-value = 0.217), or duration of diabetes (p-value = 0.922). Conclusion RLS was not an uncommon finding in patients with type 2 diabetes mellitus, being more common among those with poor diabetes control and the presence of other complications such as neuropathy, nephropathy, and retinopathy.
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Affiliation(s)
- Nauman Ismat Butt
- Internal Medicine/Rheumatology, Azra Naheed Medical College, Superior University, Lahore, PAK
| | | | - Umaima Waris
- Medicine, Azra Naheed Medical College, Superior University, Lahore, PAK
| | - Dure Sabeh
- Medicine, Bahawal Victoria Hospital, Quaid-e-Azam Medical College, Bahawalpur, PAK
| | - Fahad Qaisar
- Medicine, Bahawal Victoria Hospital, Quaid-e-Azam Medical College, Bahawalpur, PAK
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Leung TNH, Wong KL, Chan AKC, Li AM. Common Childhood Sleep Problems and Disorders. Curr Pediatr Rev 2024; 20:27-42. [PMID: 36043722 DOI: 10.2174/1573396318666220827102018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/30/2022] [Accepted: 07/04/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sleep insufficiency and disturbances affect the physical, cognitive, and emotional well-being of children. OBJECTIVE To perform a narrative review on common sleep problems and disorders encountered in primary care for children and adolescents. METHODS A search of English literature in the Pubmed and Google Scholar databases published from 1 January 2000 till 31 October 2021 was conducted with the keywords "sleep problem" or "sleep disorder" and "child" or "adolescent". Findings in the relevant articles and cross-references were compiled. RESULTS Sleep duration and habits of children vary widely across countries with different cultural backgrounds. There is robust evidence to support the promotion of positive bedtime routines and sleep hygiene as prevention and management of sleep problems. 15-70% of parents reported their children having sleep problems or disturbances. Common sleep complaints include difficulty in initiation or maintenance of sleep, abnormal behaviors or movements, snoring or abnormal breathing, and excessive daytime sleepiness. Comprehensive sleep history and a sleep diary are the first steps for evaluation. Home video and actigraphy may be used as preliminary tools to confirm the history. Referrals to a sleep specialist for polysomnography and other tests are needed, if suspecting specific sleep disorders, such as obstructive sleep apnea and narcolepsy, needs timely intervention. Common sleep disorders in different age groups encountered in primary care are reviewed with clinical features, indications for evaluation, and treatment options summarized. CONCLUSION Screening for sleep problems shall be an integral part of each child's health care visit. It is important to evaluate the impact of common sleep problems and identify specific sleep disorders for early intervention to prevent long-term adverse outcomes.
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Affiliation(s)
- Theresa Ngan Ho Leung
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Kin Lok Wong
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Anthony Kam Chuen Chan
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Albert Martin Li
- Department of Paediatrics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China
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Sato R, Yokokawa D, Uehara T, Tsukamoto T, Noda K, Shikino K, Yanagita Y, Kojima J, Ishizuka K, Ikusaka M. Restless X syndrome: a new diagnostic family of nocturnal, restless, abnormal sensations of various body parts. Diagnosis (Berl) 2023; 10:450-451. [PMID: 37183610 DOI: 10.1515/dx-2023-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Rurika Sato
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Daiki Yokokawa
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Takanori Uehara
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Tomoko Tsukamoto
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Kazutaka Noda
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Yasutaka Yanagita
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Jumpei Kojima
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Kosuke Ishizuka
- Department of General Medicine, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
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Morais MA, Franco B, Holanda ASS, Simino LADP, Manconi M, Torsoni A, Esteves AM. Effectiveness of exercise and pramipexole in the treatment of restless leg syndrome: Implications on the dopaminergic system and PTPRD. Sleep Med 2023; 110:201-211. [PMID: 37633178 DOI: 10.1016/j.sleep.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/27/2023] [Accepted: 08/12/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVE Dopaminergic dysfunction, iron reduction and variations in the PTPRD gene (protein tyrosine phosphatase receptor type delta) may be associated with restless leg syndrome (RLS). Here, we evaluate the effect of pramipexole (PPX) and exercise on genes and proteins associated with RLS and on sleep patterns in spontaneously hypertensive rats (SHR). METHODS Animals were distributed into 4 groups: 1) Control (CTRL); 2) Exercise (EX); 3) Exercise and pramipexole (EX + PPX); and 4) Pramipexole (PPX). PPX treatment was performed daily (0.125 mg/kg), while exercise was conducted over 5 sessions per week, both for 4 weeks. RESULTS EX + PPX increased the protein levels of PTPRD, reduced the protein levels of the enzyme tyrosine hydroxylase (TH) and improved sleep parameters in both cycles; on the other hand, the use of PPX reduced mRNA and protein levels of PTPRD and TH but improved the sleep pattern in the light cycle. However, in the dark cycle, pramipexole caused the worsening of symptoms. CONCLUSIONS We suggest that the improvement in sleep pattern by EX + PPX may be associated with the increased protein levels of PTPRD and that EX + PPX can reverse the negative effects of PPX.
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Affiliation(s)
- Milca A Morais
- Faculdade de Ciências Aplicadas - Universidade Estadual de Campinas, Street Pedro Zaccaria, 1300, 13484-350, Limeira, Brazil.
| | - Beatriz Franco
- Faculdade de Educação Física - Universidade Estadual de Campinas, Érico Veríssimo Avenue, 701 - Cidade Universitária Zeferino Vaz, Campinas, Brazil.
| | - Alessandro S S Holanda
- Faculdade de Ciências Aplicadas - Universidade Estadual de Campinas, Street Pedro Zaccaria, 1300, 13484-350, Limeira, Brazil.
| | - Laís Angélica de Paula Simino
- Faculdade de Ciências Aplicadas - Universidade Estadual de Campinas, Street Pedro Zaccaria, 1300, 13484-350, Limeira, Brazil.
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano (EOC), Lugano, Via Tesserete 46, Lugano CH-6903, Switzerland.
| | - Adriana Torsoni
- Faculdade de Ciências Aplicadas - Universidade Estadual de Campinas, Street Pedro Zaccaria, 1300, 13484-350, Limeira, Brazil.
| | - Andrea M Esteves
- Faculdade de Ciências Aplicadas - Universidade Estadual de Campinas, Street Pedro Zaccaria, 1300, 13484-350, Limeira, Brazil.
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Lauretani F, Testa C, Salvi M, Zucchini I, Giallauria F, Maggio M. Clinical Evaluation of Sleep Disorders in Parkinson’s Disease. Brain Sci 2023; 13:brainsci13040609. [PMID: 37190574 DOI: 10.3390/brainsci13040609] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/07/2023] Open
Abstract
The paradigm of the framing of Parkinson’s disease (PD) has undergone significant revision in recent years, making this neurodegenerative disease a multi-behavioral disorder rather than a purely motor disease. PD affects not only the “classic” substantia nigra at the subthalamic nuclei level but also the nerve nuclei, which are responsible for sleep regulation. Sleep disturbances are the clinical manifestations of Parkinson’s disease that most negatively affect the quality of life of patients and their caregivers. First-choice treatments for Parkinson’s disease determine amazing effects on improving motor functions. However, it is still little known whether they can affect the quantity and quality of sleep in these patients. In this perspective article, we will analyze the treatments available for this specific clinical setting, hypothesizing a therapeutic approach in relation to neurodegenerative disease state.
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Affiliation(s)
- Fulvio Lauretani
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Clinic Geriatric Unit and Cognitive and Motor Center, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy
| | - Crescenzo Testa
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Marco Salvi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Irene Zucchini
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Francesco Giallauria
- Department of Translational Medical Sciences, “Federico II” University of Naples, Via S. Pansini 5, 80131 Naples, Italy
| | - Marcello Maggio
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Clinic Geriatric Unit and Cognitive and Motor Center, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy
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Restless Legs Syndrome and Periodic Limb Movements of Sleep: From Neurophysiology to Clinical Practice. J Clin Neurophysiol 2023; 40:215-223. [PMID: 36872500 DOI: 10.1097/wnp.0000000000000934] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
SUMMARY This article summarizes restless legs syndrome (RLS), periodic limb movements of sleep, and periodic limb movement disorder. RLS is a common sleep disorder with a prevalence of 5% to 15% in the general population. RLS can present in childhood, and incidence increases with age. RLS can be idiopathic or secondary to iron deficiency, chronic renal failure, peripheral neuropathy, and medications such as antidepressants (with higher rates for mirtazapine and venlafaxine, while bupropion may reduce symptoms at least in the short term), dopamine antagonists (neuroleptic antipsychotic agents and antinausea medications), and possibly antihistamines. Management includes pharmacologic agents (dopaminergic agents, alpha-2 delta calcium channel ligands, opioids, benzodiazepines) and nonpharmacologic therapies (iron supplementation, behavioral management). Periodic limb movements of sleep are an electrophysiologic finding commonly accompanying RLS. On the other hand, most individuals with periodic limb movements of sleep do not have RLS. The clinical significance of the movements has been argued. Periodic limb movement disorder is a distinct sleep disorder that arises in individuals without RLS and is a diagnosis of exclusion.
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Liu Z, Guan R, Pan L. Exploration of restless legs syndrome under the new concept: A review. Medicine (Baltimore) 2022; 101:e32324. [PMID: 36550837 PMCID: PMC9771278 DOI: 10.1097/md.0000000000032324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Restless leg syndrome (Restless legs syndrome, RLS) is a common neurological disorder. The pathogenesis of RLS remains unknown, and recent pathophysiological developments have shown the contribution of various genetic markers, neurotransmitter dysfunction, and iron deficiency to the disease, as well as other unidentified contributing mechanisms, particularly chronic renal dysfunction. RLS enhancement syndrome is frequently observed in patients with RLS who have received long-term dopamine agonist therapy, manifesting as a worsening of RLS symptoms, usually associated with an increase in the dose of dopamine agonist. Some patients with RLS can adequately control their symptoms with non-pharmacological measures such as massage and warm baths. First-line treatment options include iron supplementation for those with evidence of reduced iron stores, or gabapentin or pregabalin, as well as dopamine agonists, such as pramipexole. Second-line therapies include opioids such as tramadol. RLS seriously affects the quality of life of patients, and because its pathogenesis is unclear, more biological evidence and treatment methods need to be explored.
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Affiliation(s)
- Zhao Liu
- Heilongjiang University of Traditional Chinese Medicine, Harbin, Heilongjiang Province
- *Correspondence: Zhao Liu, Heilongjiang University of Traditional Chinese Medicine, 24 Heping Road, Harbin 150006, Heilongjiang Province (e-mail: )
| | - Ruiqian Guan
- Heilongjiang University of Traditional Chinese Medicine, Harbin, Heilongjiang Province
- Second Affiliated Hospital of Heilongjiang University of Traditional Chinese Medicine, Harbin, Heilongjiang Province
| | - Limin Pan
- Heilongjiang University of Traditional Chinese Medicine, Harbin, Heilongjiang Province
- First Affiliated Hospital of Heilongjiang University of Traditional Chinese Medicine, Harbin, Heilongjiang Province
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McLafferty LP, Spada M, Gopalan P. Pharmacologic Treatment of Sleep Disorders in Pregnancy. Sleep Med Clin 2022; 17:445-452. [PMID: 36150806 DOI: 10.1016/j.jsmc.2022.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Pregnancy is a unique physiologic state whose characteristics often predispose women to new-onset sleep disturbances or exacerbations of preexisting sleep disorders. Pregnancy-related factors that can disrupt sleep include heartburn, nocturnal oxytocin secretion, nocturia, and fetal movement. Sleep disorders in pregnancy include insomnia (primary and secondary), restless legs syndrome, and narcolepsy.
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Affiliation(s)
- Laura P McLafferty
- Department of Psychiatry and Human Behavior, Thomas Jefferson University, Thompson Building, Suite 1652, 1020 Sansom Street, Philadelphia, PA 19107, USA.
| | - Meredith Spada
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Priya Gopalan
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
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Treatment initiation and utilization patterns of pharmacotherapies for early-onset idiopathic restless legs syndrome. Sleep Med 2022; 96:70-78. [DOI: 10.1016/j.sleep.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/27/2022] [Accepted: 05/06/2022] [Indexed: 11/23/2022]
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Garg A, Chilakamarri P, Koo BB. Diagnostic and Treatment Considerations in Restless Legs Syndrome Complicated by Diabetic Neuropathy. Curr Diab Rep 2021; 21:66. [PMID: 34950962 DOI: 10.1007/s11892-021-01431-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Diabetic neuropathy from type I diabetes (DMI), type II diabetes (DMII), or gestational diabetes commonly occurs concurrently with restless legs syndrome (RLS) with an estimated prevalence in DMII specifically of 17.7 to 45%. The diagnosis of RLS can be obscured by symptoms of peripheral neuropathy, which may be similar to those of RLS, but also by other RLS mimics, including nocturnal leg cramps or akathisia. The purpose of this review is to outline a framework for considering comorbid diabetic neuropathy and RLS by discussing RLS and its association with peripheral nerve disease, diabetes, and sleep disruption. Treatment for patients with both diabetic neuropathy and RLS may differ from treatment of persons with solely RLS or diabetic neuropathy; key points in this difference are discussed. Finally, a treatment algorithm is provided to guide the approach to treating patients with comorbid RLS and diabetic neuropathy. RECENT FINDINGS There have been several revisions of the RLS diagnostic criteria which in addition to the main four essential criteria of having (1) an urge to move the legs which is (2) exacerbated by rest, (3) relieved temporarily by movement, and (4) occurs in the evening or night time, now includes a consideration for RLS mimics, requiring that (5) symptoms not be explained by any other symptoms. Additionally, the treatment of both diabetic neuropathy and RLS has evolved to focus first on controlling the blood glucose, avoiding exacerbating medications, supplementing with iron if serum ferritin is low, and starting pharmacotherapy with alpha-2-delta ligands such as gabapentin or pregabalin. Knowledge of the prevalence of peripheral neuropathy with RLS, revised RLS diagnostic criteria, and a general treatment algorithm for the combination of peripheral neuropathy and RLS is critical to providing appropriate care to patients suffering from these two diseases.
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Affiliation(s)
- Anisha Garg
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Priyanka Chilakamarri
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
- Department of Neurology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Brian B Koo
- Department of Neurology, Yale University, New Haven, CT, USA.
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Moderie C, Carrier J, Dang-Vu TT. [Sleep disorders in patients with a neurocognitive disorder]. Encephale 2021; 48:325-334. [PMID: 34916075 DOI: 10.1016/j.encep.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/24/2021] [Accepted: 08/29/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Sleep disorders are prevalent in patients with a neurocognitive disorder, and diagnosis and treatment in these patients remain challenging in clinical practice. METHODS This narrative review offers a systematic approach to diagnose and treat sleep disorders in neurocognitive disorders. RESULTS Alzheimer's disease is often associated with circadian rhythm disorders, chronic insomnia, and sleep apnea-hypopnea syndrome. Alpha-synucleinopathies (e.g., Parkinson's disease and Lewy body dementia) are often associated with a rapid eye movement sleep behavior disorder, restless legs syndrome, chronic insomnia, and sleep apnea-hypopnea syndrome. A focused history allows to diagnose most sleep disorders. Clinicians should ensure to gather the following information in all patients with a neurocognitive disorder: (1) the presence of difficulties falling asleep or staying asleep, (2) the impact of sleep disturbances on daily functioning (fatigue, sleepiness and other daytime consequences), and (3) abnormal movements in sleep. Sleep diaries and questionnaires can assist clinicians in screening for specific sleep disorders. Polysomnography is recommended if a rapid eye movement sleep behavior disorder or a sleep apnea-hypopnea syndrome are suspected. Sleep complaints should prompt clinicians to ensure that comorbidities interfering with sleep are properly managed. The main treatment for moderate to severe obstructive sleep apnea-hypopnea syndrome remains continuous positive airway pressure, as its efficacy has been demonstrated in patients with neurocognitive disorders. Medications should also be reviewed, and time of administration should be optimized (diuretics and stimulating medications in the morning, sedating medications in the evening). Importantly, cholinesterase inhibitors (especially donepezil) may trigger insomnia. Switching to morning dosing or to an alternative drug may help. Cognitive-behavioral therapy for insomnia is indicated to treat chronic insomnia in neurocognitive disorders. False beliefs regarding sleep should be addressed with the patient and their caregiver. The sleep environment should be optimized (decrease light exposure at night, minimize noise, avoid taking vital signs, etc.). Sleep restriction can be considered as patients with a neurocognitive disorder often spend too much time in bed. The need for naps should be assessed case by case as naps may contribute to insomnia in some patients but allow others to complete their diurnal activities. Trazodone (50mg) may also be used under certain circumstances in chronic insomnia. Recent evidence does not support a role for exogenous melatonin in patients with a neucognitive disorder and insomnia. Patients in long-term care facilities are often deprived of an adequate diurnal exposure to light. Increasing daytime exposure to light may improve sleep and mood. Patients with circadian rhythm disorders can also benefit from light therapy (morning bright light therapy in case of phase delay and evening bright light therapy in case of phase advance). Rapid eye movement sleep behavior disorder can lead to violent behaviors, and the sleeping environment should be secured (e.g., mattress on the floor, remove surrounding objects). Medication exacerbating this disorder should be stopped if possible. High dose melatonin (6 to 18mg) or low dose clonazepam (0.125-0.25mg) at bedtime may be used to reduce symptoms. Melatonin is preferred in first-line as it is generally well tolerated with few side effects. Patients with restless legs syndrome should be investigated for iron deficiency. Medication decreasing dopaminergic activity should be reduced or stopped if possible. Behavioral strategies such as exercise and leg massages may be beneficial. Low-dose dopamine agonists (such as pramipexole 0.125mg two hours before bedtime) can be used to treat the condition, but a prolonged treatment may paradoxically worsen the symptoms. Alpha-2-delta calcium channel ligands can also be used while monitoring for the risk of falls. CONCLUSION Multiple and sustained nonpharmacological approaches are recommended for the treatment of sleep disturbances in patients with neurocognitive disorder. Pharmacological indications remain limited, and further randomized clinical trials integrating a multimodal approach are warranted to evaluate the treatment of sleep disorders in specific neurocognitive disorders.
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Affiliation(s)
- C Moderie
- Département de psychiatrie, université McGill, Montréal, Québec, Canada
| | - J Carrier
- Centre de recherche de l'institut universitaire de gériatrie de Montréal, Montréal, Québec, Canada; Département de psychologie, université de Montréal, Montréal, Québec, Canada; Centre d'études avancées en médecine du sommeil, Montréal, Québec, Canada
| | - T T Dang-Vu
- Centre de recherche de l'institut universitaire de gériatrie de Montréal, Montréal, Québec, Canada; Département de psychologie, université de Montréal, Montréal, Québec, Canada; Département de santé, kinésiologie et physiologie appliquée, centre d'études en neurobiologie comportementale et centre PERFORM, université Concordia, Montréal, Québec, Canada.
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Su YC, Guo YH, Liao CL, Lin YC. Effectiveness and Safety of Botulinum Toxin Type A in Treatment of Restless Legs Syndrome: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2021; 9:healthcare9111538. [PMID: 34828584 PMCID: PMC8623507 DOI: 10.3390/healthcare9111538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 11/27/2022] Open
Abstract
Our study aimed to investigate the effectiveness and safety of botulinum toxin type A in patients with restless legs syndrome. We searched electronic databases, including PubMed, Cochrane Library, and Web of Science, up to 12 June 2021, for published articles. We enrolled randomized controlled clinical trials and non-randomized controlled studies involving patients with restless legs syndrome who were treated with botulinum toxin. Quality assessment was performed using the Cochrane risk of bias tool and Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies. As for the results, we included four articles comprising 62 participants, two studies were randomized controlled trials. Improvement in International Restless Legs Syndrome Study Group (IRLSSG) rating scale was observed in three studies. Adverse events were temporary and self-limited. Meta-analyses were performed, including the two randomized controlled trials with 27 participants. Compared with placebo, botulinum toxin injection significantly reduced scores of IRLSSG rating scale (SMD, −0.819, 95% confidence interval [CI], −1.377 to −0.262). A total of 11.8% (95% CI, 0.7–72.4%) of patients reported at least one adverse event. In conclusion, botulinum toxin injection may relieve restless legs syndrome related symptoms. However, decisive conclusions cannot be drawn because of the small number of patients included in our meta-analysis. Large-scale, randomized controlled trials are warranted to discover the optimal dose, safety, and long-term effect of intervention with botulinum toxin type A for patients with restless legs syndrome.
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Affiliation(s)
- Yu-Chi Su
- National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70428, Taiwan;
| | - Yao-Hong Guo
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70428, Taiwan;
| | - Chung-Lun Liao
- School of Medicine, College of Medicine, National Cheng Kung University, Tainan 70428, Taiwan;
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70428, Taiwan;
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan 70428, Taiwan
- Correspondence:
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14
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Winkelman JW. High National Rates of High-Dose Dopamine Agonist Prescribing for RLS. Sleep 2021; 45:6356055. [PMID: 34417810 PMCID: PMC8842153 DOI: 10.1093/sleep/zsab212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/12/2021] [Indexed: 11/14/2022] Open
Abstract
Study Objectives Long-term dopamine agonist (DA) use in restless legs syndrome (RLS) is associated with augmentation, a dose-related symptom worsening leading to further dose escalation to manage RLS. This study investigated rates and factors of high-dose DA prescribing in US RLS patients. Methods This retrospective analysis examined data from a US longitudinal prescriptions database (October 2017–September 2018). Patients diagnosed with RLS (ICD-10 G255.81) without Parkinson’s disease who were prescribed ropinirole, pramipexole, and/or rotigotine were included. Daily DA dosage was categorized: LOW/MID (US Food and Drug Administration [FDA]-approved/guideline or slightly above FDA-approved [pramipexole]); HIGH (101%–149%); VERY HIGH (>150%). Patient counts were converted to US national estimates. Logistic regression of patient counts evaluated factors associated with HIGH/VERY HIGH DA dosing. Results Of 670,404 RLS patients (131,289,331 therapy days), 58.8% were prescribed DA therapy. Overall, 19.1% of RLS patients were prescribed DAs above maximum FDA-approved/guideline daily doses—over half of these were >150% maximum recommended doses; 67.6% of HIGH/VERY HIGH-dose prescriptions were pramipexole (OR [95% CI] pramipexole vs ropinirole, 5.8 [5.7 to 6.0]). The highest 1% of DA prescriptions were ≥10× the FDA-recommended maximum daily dose. Rates of HIGH/VERY HIGH DA dosing increased with patient age. Twice as many neurologists (31.1%) prescribed HIGH/VERY HIGH doses vs other specialties (OR [95% CI], 2.1 [1.2 to 2.0]). Conclusions Approximately 20% of DA-treated RLS patients were prescribed doses above the approved and guideline daily maximum. Pramipexole, Neurology as specialty, and patient age were independently associated with HIGH/VERY HIGH DA dosing. Increased education is warranted regarding risks of high-dose DA exposure in RLS.
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15
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Silber MH, Buchfuhrer MJ, Earley CJ, Koo BB, Manconi M, Winkelman JW. The Management of Restless Legs Syndrome: An Updated Algorithm. Mayo Clin Proc 2021; 96:1921-1937. [PMID: 34218864 DOI: 10.1016/j.mayocp.2020.12.026] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/13/2020] [Accepted: 12/28/2020] [Indexed: 01/26/2023]
Abstract
Restless legs syndrome (RLS) is a common disorder. The population prevalence is 1.5% to 2.7% in a subgroup of patients having more severe RLS with symptoms occurring 2 or more times a week and causing at least moderate distress. It is important for primary care physicians to be familiar with the disorder and its management. Much has changed in the management of RLS since our previous revised algorithm was published in 2013. This updated algorithm was written by members of the Scientific and Medical Advisory Board of the RLS Foundation based on scientific evidence and expert opinion. A literature search was performed using PubMed identifying all articles on RLS from 2012 to 2020. The management of RLS is considered under the following headings: General Considerations; Intermittent RLS; Chronic Persistent RLS; Refractory RLS; Special Circumstances; and Alternative, Investigative, and Potential Future Therapies. Nonpharmacologic approaches, including mental alerting activities, avoidance of substances or medications that may exacerbate RLS, and oral and intravenous iron supplementation, are outlined. The choice of an alpha2-delta ligand as first-line therapy for chronic persistent RLS with dopamine agonists as a second-line option is explained. We discuss the available drugs, the factors determining which to use, and their adverse effects. We define refractory RLS and describe management approaches, including combination therapy and the use of high-potency opioids. Treatment of RLS in pregnancy and childhood is discussed.
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Affiliation(s)
- Michael H Silber
- Center for Sleep Medicine and Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN.
| | - Mark J Buchfuhrer
- Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, CA
| | - Christopher J Earley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brian B Koo
- Department of Neurology, Yale University, New Haven, CT
| | - Mauro Manconi
- Sleep Medicine, Neurocenter of Southern Switzerland, Ospedale Civico, and Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Department of Neurology, University Hospital, Inselspital, Bern, Switzerland
| | - John W Winkelman
- Departments of Psychiatry and Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Cambridge, MA
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16
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Umbreit A, Sinha S, Kolla BP, Mansukhani MP. Challenges in the Treatment of Restless Legs Syndrome: A Case Report. J Prim Care Community Health 2021; 12:21501327211019590. [PMID: 34032164 PMCID: PMC8155758 DOI: 10.1177/21501327211019590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Treatment resistant restless legs syndrome (RLS) in the setting of psychiatric
comorbidities can be difficult to manage. Our patient is a 69-year-old Caucasian gentleman
with bipolar disorder type I, unspecified anxiety disorder, obstructive sleep apnea (OSA),
and treatment-refractory RLS. At initial presentation, the patient’s prescribed medication
regimen included fluoxetine 40 mg daily, gabapentin 800 mg in the morning and 3200 mg at
bedtime, pramipexole 0.375 mg daily, lamotrigine 200 mg daily, trazodone 200 mg at
bedtime, and temazepam 15 to 30 mg as needed for insomnia and RLS. Over the course of
nearly 4 years, treatment interventions for this patient’s RLS included: cognitive
behavioral therapy for insomnia, discontinuation of exacerbating medications, switching
dopamine agonists, use of pregabalin and iron supplement. This report demonstrates a
challenging case of RLS in the setting of psychiatric comorbidities, development of
augmentation, and polypharmacy.
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Affiliation(s)
| | - Shirshendu Sinha
- Southwest Minnesota Region, Mankato, MN, USA.,Mayo Clinic, Rochester, MN, USA
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17
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Buchfuhrer MJ, Baker FC, Singh H, Kolotovska V, Adlou B, Anand H, de Zambotti M, Ismail M, Raghunathan S, Charlesworth JD. Noninvasive neuromodulation reduces symptoms of restless legs syndrome. J Clin Sleep Med 2021; 17:1685-1694. [PMID: 33949942 DOI: 10.5664/jcsm.9404] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Restless legs syndrome (RLS) is a common neurological disorder characterized by an uncontrollable nocturnal urge to move the legs and often associated with chronic sleep disturbances. The most common treatments for RLS are medications that can have debilitating side-effects. Here, we evaluated a novel alternative modality of RLS treatment, noninvasive bilateral electrical stimulation of the common peroneal nerve. METHODS To assess the impact of this noninvasive peripheral nerve stimulation (NPNS) approach on RLS symptomatology, we conducted a multi-site randomized crossover study comparing NPNS to sham. RLS patients with moderate to severe RLS (n=37) self-administered NPNS and sham nightly for 14 days per treatment in randomized order. RESULTS NPNS resulted in a reduction in RLS severity of 6.81 points on the International RLS Rating Scale (IRLS) relative to 3.38 for sham (p<0.01) and a 66% clinically significant responder rate on the Clinical Global Impressions-Improvement (CGI-I) scale compared to 17% for sham (p<0.01). Subgroup analysis indicated that medication-resistant and medication-naïve participants both exhibited similarly robust responses. There were no moderate or serious device-related adverse events. CONCLUSIONS These results suggest that NPNS could be a promising alternative to pharmacological therapies for RLS and could provide a solution for medication-resistant RLS patients and for medication-naïve RLS patients who are unwilling or unable to take medication. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Noninvasive Peripheral Nerve Stimulation for Restless Legs Syndrome; Identifier: NCT04700683; URL: https://clinicaltrials.gov/ct2/show/NCT04700683.
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Affiliation(s)
- Mark J Buchfuhrer
- Stanford University School of Medicine, Stanford, CA; Private Practice, Downey, CA
| | - Fiona C Baker
- Center for Health Sciences, SRI International, Menlo Park, CA
| | | | - Viktoriia Kolotovska
- Sleep Medicine Specialists of California, San Ramon, CA.,Noctrix Health, Inc., Oakland, CA
| | | | | | | | - Mehvish Ismail
- Center for Health Sciences, SRI International, Menlo Park, CA
| | - Shriram Raghunathan
- Stanford University School of Medicine, Stanford, CA; Private Practice, Downey, CA
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18
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Yıldırım E, Apaydın H. Zinc and Magnesium Levels of Pregnant Women with Restless Leg Syndrome and Their Relationship with Anxiety: A Case-Control Study. Biol Trace Elem Res 2021; 199:1674-1685. [PMID: 32676936 DOI: 10.1007/s12011-020-02287-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/10/2020] [Indexed: 10/23/2022]
Abstract
Restless leg syndrome (RLS) is a multifactorial movement disorder, and pregnancy is seen as a risk factor. This study aims to determine the clinical and psychiatric causes of RLS with a case-control study. The hemogram, biochemistry data, thyroid function tests, and serum element levels of healthy pregnant women (n = 134) and pregnant women diagnosed with RLS (n = 119) were compared. Total Ca, Mg, K, and Na concentrations were measured with an inductively coupled plasma optical emission spectrometry (ICP-OES), and an atomic absorption spectrophotometer was used to measure total concentrations of Zn in all samples. The Beck Anxiety Inventory (BAI), the Beck Depression Inventory (BDI), and the Pittsburg Sleep Quality Index (PSQI) scores were also compared in both groups. Sonographic measurements showed that the fetal biparietal diameter and femur lengths were higher in the RLS group (p = 0.001, p = 0.048, respectively), and abortion history was higher in the RLS group (p = 0.016). Magnesium and zinc levels were lower (p < 0.001 for both) and BAI and PSQI scores were higher (p < 0.001 for both) in the RLS group, and there was no difference between the BDI (p = 0.269) scores. A statistically significant relationship was detected between the BAI and RLS scores in the control and RLS groups (p < 0.001 for both). This is the first study to show that magnesium and zinc deficiency may play a role in the etiology of RLS during pregnancy; the results also showed adverse perinatal outcomes such as high miscarriage.
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Affiliation(s)
- Engin Yıldırım
- Department of Obstetrics and Gynecology, Hitit University, Faculty of Medicine, Ciflikcayiri Street, İkbalkent Campus, 19200, Corum, Turkey.
| | - Hakan Apaydın
- Spectrophotometric Analysis Laboratory, HUBTUAM Research Center, Hitit University, Faculty of Engineering, North Campus, Ring Road Boulevard, 19030, Çorum, Turkey
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19
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Wipper B, Winkelman JW. The Long-Term Psychiatric and Cardiovascular Morbidity and Mortality of Restless Legs Syndrome and Periodic Limb Movements of Sleep. Sleep Med Clin 2021; 16:279-288. [PMID: 33985653 DOI: 10.1016/j.jsmc.2021.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Restless legs syndrome (RLS) is a sensory-motor neurological disorder that is associated with high levels of distress and sleep disturbance. Cross-sectional and longitudinal evidence suggests that individuals suffering from RLS may be at an increased risk of certain psychiatric illnesses and cardiovascular diseases. There also is evidence for increased mortality rates in RLS patients, although contrasting results do exist. Periodic limb movements of sleep (PLMS), repetitive leg movement observed in most RLS patients, and sleep disturbance may mediate the relationship between RLS and long-term morbidity. This article summarizes the literature investigating the potential consequences of both RLS and PLMS.
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Affiliation(s)
- Benjamin Wipper
- Sleep Disorders Clinical Research Program, Massachusetts General Hospital, Harvard Medical School, One Bowdoin Square, 10th Floor, Boston, MA 02114, USA
| | - John W Winkelman
- Sleep Disorders Clinical Research Program, Massachusetts General Hospital, Harvard Medical School, One Bowdoin Square, 10th Floor, Boston, MA 02114, USA; Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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20
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Naqvi IH, Ahmed J, Salim M, Ubaid M, Malik F, Afzal R, Ashrafi MM, Khan MAA. Restless Leg Syndrome in Patients with Liver Cirrhosis! Its Frequency, Severity, and Correlation. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2021; 20:465-472. [PMID: 33292126 DOI: 10.2174/1871527319666201208102104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/21/2020] [Accepted: 10/05/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Restless leg syndrome (RLS) has been recognized as a typical additional manifestation among patients with cirrhosis of the liver. RLS prevalence in liver cirrhosis further worsens the quality of life, which has already been compromised with the disease-related complications of cirrhosis itself. AIMS The study aimed to determine the frequency and severity of Restless Leg Syndrome (RLS) among patients with cirrhosis of the liver and to correlate its severity with the severity of cirrhosis. METHODS This prospective cross-sectional study was carried out at Ruth K.M. Pfau Civil Hospital (Karachi, Pakistan) from December 2019 to February 2020. Three hundred and fifteen cirrhotic patients with any etiology were included in the study after informed written consent. Restless leg syndrome with its severity was determined in all cirrhotic patients. For continuous variables, means and medians with standard deviations were calculated, while percentages and proportions were used for discrete variables. Spearman correlation was used to find significance between RLS Severity Score (RSS) and Model of End-stage Liver Disease MELD Score. A p value of < 0.05 was considered significant for all analyses. RESULTS The frequency of RLS among cirrhotic patients was 38.4%. More than half (54.5%) of the patients had severe RLS. Viral related hepatitis C and hepatitis B were the most common cause of cirrhosis of the liver (57.8% and 30.8%). A significant difference was found between as patients both with or without RLS in terms of age (p=0.003), gender (p=0.005), hemoglobin (p=0.00), and serum albumin (p=0.01). No significant association was found between RLS severity score and MELD Score (p=0.693). CONCLUSION Prevalence of RLS is very high among cirrhotic patients, but no correlation was found between the severity of RLS and cirrhosis. Further studies should be carried out to assess the quality of life in cirrhotic patients having RLS.
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Affiliation(s)
- Iftikhar Haider Naqvi
- Department of Medicine, Dow University of Health Sciences & Civil Hospital Karachi, Mission Road Karachi, Sindh 74200, Pakistan
| | - Jawad Ahmed
- Dow Medical College, Dow University of Health Sciences, Mission Road Karachi, Sindh 74200, Pakistan
| | - Maliha Salim
- Dow Medical College, Dow University of Health Sciences, Mission Road Karachi, Sindh 74200, Pakistan
| | - Muhammad Ubaid
- Department of Medicine, Dow University of Health Sciences & Civil Hospital Karachi, Mission Road Karachi, Sindh 74200, Pakistan
| | - Farheen Malik
- Dow Medical College, Dow University of Health Sciences, Mission Road Karachi, Sindh 74200, Pakistan
| | - Razna Afzal
- Dow Medical College, Dow University of Health Sciences, Mission Road Karachi, Sindh 74200, Pakistan
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21
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Gossard TR, Trotti LM, Videnovic A, St Louis EK. Restless Legs Syndrome: Contemporary Diagnosis and Treatment. Neurotherapeutics 2021; 18:140-155. [PMID: 33880737 PMCID: PMC8116476 DOI: 10.1007/s13311-021-01019-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 12/12/2022] Open
Abstract
Restless legs syndrome (RLS) is characterized by an uncomfortable urge to move the legs while at rest, relief upon movement or getting up to walk, and worsened symptom severity at night. RLS may be primary (idiopathic) or secondary to pregnancy or a variety of systemic disorders, especially iron deficiency, and chronic renal insufficiency. Genetic predisposition with a family history is common. The pathogenesis of RLS remains unclear but is likely to involve central nervous system dopaminergic dysfunction, as well as other, undefined contributing mechanisms. Evaluation begins with a thorough history and examination, and iron measures, including ferritin and transferrin saturation, should be checked at presentation and with worsened symptoms, especially when augmentation develops. Augmentation is characterized by more intense symptom severity, earlier symptom occurrence, and often, symptom spread from the legs to the arms or other body regions. Some people with RLS have adequate symptom control with non-pharmacological measures such as massage or temperate baths. First-line management options include iron-replacement therapy in those with evidence for reduced body-iron stores or, alternatively, with prescribed gabapentin or pregabalin, and dopamine agonists such as pramipexole, ropinirole, and rotigotine. Second-line therapies include intravenous iron infusion in those who are intolerant of oral iron and/or those having augmentation with intense, severe RLS symptoms, and opioids including tramadol, oxycodone, and methadone. RLS significantly impacts patients' quality of life and remains a therapeutic area sorely in need of innovation and a further pipeline of new, biologically informed therapies.
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Affiliation(s)
- Thomas R Gossard
- Mayo Center for Sleep Medicine, 200 First Street SW, Rochester, MN, 55905, USA
| | | | | | - Erik K St Louis
- Mayo Center for Sleep Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
- Departments of Neurology and Clinical and Translational Research, Mayo Clinic Southwest Wisconsin, La Crosse, Wisconsin, USA.
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22
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Mondello S, Kobeissy FH, Mechref Y, Zhao J, El Hayek S, Zibara K, Moresco M, Plazzi G, Cosentino FII, Ferri R. Searching for Novel Candidate Biomarkers of RLS in Blood by Proteomic Analysis. Nat Sci Sleep 2021; 13:873-883. [PMID: 34234594 PMCID: PMC8243594 DOI: 10.2147/nss.s311801] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/28/2021] [Indexed: 01/03/2023] Open
Abstract
PURPOSE We performed comparative proteomic analyses of blood of patients with RLS and healthy individuals aiming to identify potential biomarker and therapeutic target candidate for RLS. PATIENTS AND METHODS Blood serum samples from 12 patients with a clinical diagnosis of RLS (8 females and 4 males, with a mean age of 68.52 years) and 10 healthy controls (5 females and 5 males, with a mean age of 67.61 years) underwent proteomic profiling by liquid chromatography coupled with tandem mass spectrometry. Pathway analysis incorporating protein-protein interaction networks was carried out to identify pathological processes linked to the differentially expressed proteins. RESULTS We quantified 272 proteins in patients with RLS and healthy controls, of which 243 were shared. Five proteins - apolipoprotein C-II, leucine-rich alpha-2-glycoprotein 1, FLJ92374, extracellular matrix protein 1, and FLJ93143 - were substantially increased in RLS patients, whereas nine proteins - vitamin D-binding protein, FLJ78071, alpha-1-antitrypsin, CD5 antigen-like, haptoglobin, fibrinogen alpha chain, complement factor H-related protein 1, platelet factor 4, and plasma protease C1 inhibitor - were decreased. Bioinformatics analyses revealed that these proteins were linked to 1) inflammatory and immune response, and complement activation, 2) brain-related development, cell aging, and memory disorders, 3) pregnancy and associated complications, 4) myocardial infarction, and 5) reactive oxygen species generation and subsequent diabetes mellitus. CONCLUSION Our findings shed light on the multifactorial nature of RLS and identified a set of circulating proteins that may have clinical importance as biomarkers and therapeutic targets.
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Affiliation(s)
- Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Firas H Kobeissy
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yehia Mechref
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jingfu Zhao
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, TX, 79409, USA
| | - Samer El Hayek
- Department of Psychiatry, American University of Beirut, Beirut, Lebanon
| | - Kazem Zibara
- Department of Biology, Faculty of Sciences-I, PRASE, DSST, Lebanese University, Beirut, Lebanon
| | - Monica Moresco
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | | | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute - IRCCS, Troina, Italy
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Akhmadulina AO, Levin OS, Poluektov MG. [Restless legs syndrome in Parkinson's disease]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:80-88. [PMID: 33205935 DOI: 10.17116/jnevro202012010280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Disturbances in sleep and wakefulness are important symptoms of Parkinson's disease (PD) and are associated with negative effects on patients' quality of life. The analysis of literature on the relationship between RLS and PD revealed three main hypotheses explaining the relatively high incidence of RLS in PD: (1) RLS can be considered as an early (prodromal) manifestation or a predictor of PD that can outpace its main symptoms by several years (by analogy with conduct disorder during sleep with REM); (2) the high incidence of RLS in the advanced stage of PD may be associated with augmentation of previously latent RLS symptoms during prolonged dopaminergic therapy of PD; (3) a significant proportion of RLS cases in PD patients are not «classical» RLS, but represent, for example, manifestations of motor or non-motor fluctuations or a special form of stereotypy in the legs. Further research is needed to determine if any of these statements are true.
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Affiliation(s)
- A O Akhmadulina
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - O S Levin
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - M G Poluektov
- Sechenov First Moscow Medical University, Moscow, Russia
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24
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Badenoch J, Searle T, Watson I, Cavanna AE. Sensory symptoms in body-focused repetitive behaviors, restless legs syndrome, and Tourette syndrome: An overlap? Neurosci Biobehav Rev 2020; 119:320-332. [PMID: 33086129 DOI: 10.1016/j.neubiorev.2020.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 12/25/2022]
Abstract
Tourette syndrome (TS) is a neurodevelopmental condition characterized by multiple tics. Sensory symptoms play a key role in the clinical phenomenology and pathophysiology of TS, as most patients report premonitory urges driving tic expression. Interestingly, sensory symptoms have also been reported in other conditions characterized by repeated behaviors. This review explores the nature of sensory symptoms reported by patients with body focused repetitive behaviors (BFRBs, especially trichotillomania and skin picking disorder) and restless legs syndrome (RLS) in comparison to TS. A sense of mounting inner tension and reinforcement mechanisms driven by gratification and relief on expression of the tic or repetitive behavior appear to be implicated across all conditions. Subjective urges can be temporarily suppressed by patients with TS and selected BFRBs, whereas patients with RLS tend to report dysesthesia more frequently than a suppressible urge to move. The observed similarities in the phenomenology of sensory symptoms across these conditions raise the possibility of a comparable underlying pathophysiology. Preliminary findings suggest an overlap of neural pathways encompassing the insula, basal ganglia (putamen), and posterior cingulate cortex.
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Affiliation(s)
- James Badenoch
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom
| | - Tamara Searle
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom
| | - Iona Watson
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom
| | - Andrea E Cavanna
- Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom; School of Life and Health Sciences, Aston University, Birmingham, United Kingdom; University College London and Institute of Neurology, London, United Kingdom.
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25
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Zuzuárregui JRP, During EH. Sleep Issues in Parkinson's Disease and Their Management. Neurotherapeutics 2020; 17:1480-1494. [PMID: 33029723 PMCID: PMC7851262 DOI: 10.1007/s13311-020-00938-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 12/13/2022] Open
Abstract
Parkinson's disease (PD) is an alpha-synucleinopathy that leads to prominent motor symptoms including tremor, bradykinesia, and postural instability. Nonmotor symptoms including autonomic, neurocognitive, psychiatric symptoms, and sleep disturbances are also seen frequently in PD. The impact of PD on sleep is related to motor and nonmotor symptoms, in addition to the disruption of the pathways regulating sleep by central nervous system pathology. Rapid eye movement sleep behavior disorder is a parasomnia that can lead to self-injury and/or injury to partners at night. Restless legs syndrome is a subjective sensation of discomfort and urge to move the legs prior to falling asleep and can lead to insomnia and reduced sleep quality. Excessive daytime sleepiness is common in PD and exerts a negative impact on quality of life in addition to increasing the risk of falls. Obstructive sleep apnea is a breathing disorder during sleep that can cause frequent awakenings and excessive daytime sleepiness. Circadian rhythm dysfunction can lead to an advanced or delayed onset of sleep in patients and create disruption of normal sleep and wake times. All of these disorders are common in PD and can significantly reduce sleep quantity, sleep quality, or quality of life for patients and caretakers. Treatment approaches for each of these disorders are distinct and should be individualized to the patient. We review the literature regarding these common sleep issues encountered in PD and their treatment options.
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Affiliation(s)
| | - Emmanuel H During
- Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center, Palo Alto, CA, USA
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Macher S, Herster C, Holter M, Moritz M, Matzhold EM, Stojakovic T, Pieber TR, Schlenke P, Drexler C, Amrein K. The Effect of Parenteral or Oral Iron Supplementation on Fatigue, Sleep, Quality of Life and Restless Legs Syndrome in Iron-Deficient Blood Donors: A Secondary Analysis of the IronWoMan RCT. Nutrients 2020; 12:nu12051313. [PMID: 32380660 PMCID: PMC7284357 DOI: 10.3390/nu12051313] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/25/2020] [Accepted: 04/30/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Besides anemia, iron deficiency may cause more subtle symptoms, including the restless legs syndrome (RLS), the chronic fatigue syndrome (CFS) or sleeping disorders. Objective: The aim of this pre-planned secondary analysis of the IronWoMan randomized controlled trial (RCT) was to compare the frequency and severity of symptoms associated with iron deficiency before and after (intravenous or oral) iron supplementation in iron deficient blood donors. Methods/Design: Prospective, randomized, controlled, single-centre trial. (ClinicalTrials.gov: NCT01787526). Setting: Tertiary care center in Graz, Austria. Participants: 176 (138 female and 38 male) whole-blood and platelet apheresis donors aged ≥ 18 and ≤ 65 years with iron deficiency (ferritin ≤ 30ng/mL at the time of blood donation). Interventions: Intravenous iron (1 g ferric carboxymaltose, n = 86) or oral iron supplementation (10 g iron fumarate, 100 capsules, n = 90). Measurements: Clinical symptoms were evaluated by a survey before iron therapy (visit 0, V0) and after 8–12 weeks (visit 1, V1), including questions about symptoms of restless legs syndrome (RLS), chronic fatigue syndrome (CFS), sleeping disorders, quality of life and symptoms like headaches, dyspnoea, dizziness, palpitations, pica and trophic changes in fingernails or hair. Results: We found a significant improvement in the severity of symptoms for RLS, fatigue and sleep quality (p < 0.001). Furthermore, a significant decrease in headaches, dyspnoea, dizziness and palpitations was reported (p < 0.05). There was no difference between the type of iron supplementation (intravenous versus oral) and clinical outcome data. Conclusion: Iron supplementation in iron-deficient blood donors may be an effective strategy to improve symptoms related to iron deficiency and the wellbeing of blood donors.
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Affiliation(s)
- Susanne Macher
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Graz, 8036 Graz, Austria; (S.M.); (C.H.); (M.M.); (E.M.M.); (P.S.); (C.D.)
- Laboratory of the ÖGK, Friedrichgasse 18, 8010 Graz, Austria
| | - Cornelia Herster
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Graz, 8036 Graz, Austria; (S.M.); (C.H.); (M.M.); (E.M.M.); (P.S.); (C.D.)
| | - Magdalena Holter
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, 8036 Graz, Austria;
| | - Martina Moritz
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Graz, 8036 Graz, Austria; (S.M.); (C.H.); (M.M.); (E.M.M.); (P.S.); (C.D.)
| | - Eva Maria Matzhold
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Graz, 8036 Graz, Austria; (S.M.); (C.H.); (M.M.); (E.M.M.); (P.S.); (C.D.)
| | - Tatjana Stojakovic
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, University Hospital Graz, 8036 Graz, Austria;
| | - Thomas R. Pieber
- Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria;
| | - Peter Schlenke
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Graz, 8036 Graz, Austria; (S.M.); (C.H.); (M.M.); (E.M.M.); (P.S.); (C.D.)
| | - Camilla Drexler
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Graz, 8036 Graz, Austria; (S.M.); (C.H.); (M.M.); (E.M.M.); (P.S.); (C.D.)
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, 8036 Graz, Austria;
- Correspondence:
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Connor JR, Duck K, Patton S, Simpson IA, Trotti LM, Allen R, Earley CJ, Rye D. Evidence for communication of peripheral iron status to cerebrospinal fluid: clinical implications for therapeutic strategy. Fluids Barriers CNS 2020; 17:28. [PMID: 32295615 PMCID: PMC7161256 DOI: 10.1186/s12987-020-00190-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/04/2020] [Indexed: 12/22/2022] Open
Abstract
Background Iron is crucial for proper functioning of all organs including the brain. Deficiencies and excess of iron are common and contribute to substantial morbidity and mortality. Whereas iron’s involvement in erythropoiesis drives clinical practice, the guidelines informing interventional strategies for iron repletion in neurological disorders are poorly defined. The objective of this study was to determine if peripheral iron status is communicated to the brain. Methods We used a bi-chamber cell culture model of the blood–brain-barrier to determine transcytosis of iron delivered by transferrin as a metric of iron transport. In the apical chamber (representative of the blood) we placed transferrin complexed with iron59 and in the basal chamber (representative of the brain) we placed human cerebrospinal fluid. Cerebrospinal fluid (CSF) samples (N = 24) were collected via lumbar puncture. The integrity of the tight junctions were monitored throughout the experiments using RITC-Dextran. Results We demonstrate that iron transport correlates positively with plasma hemoglobin concentrations but not serum ferritin levels. Conclusions The clinical ramifications of these findings are several- fold. They suggest that erythropoietic demands for iron take precedence over brain requirements, and that the metric traditionally considered to be the most specific test reflecting total body iron stores and relied upon to inform treatment decisions–i.e., serum ferritin–may not be the preferred peripheral indicator when attempting to promote brain iron uptake. The future direction of this line of investigation is to identify the factor(s) in the CSF that influence iron transport at the level of the BBB.
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Affiliation(s)
- James R Connor
- Department of Neurosurgery, Penn State Hershey Medical Center, University Dr (H110), 850, Hershey, PA, 17033, USA. .,Department of Neural and Behavioral Sciences, Penn State Hershey Medical Center, Hershey, PA, USA.
| | - Kari Duck
- Department of Neurosurgery, Penn State Hershey Medical Center, University Dr (H110), 850, Hershey, PA, 17033, USA
| | - Stephanie Patton
- Department of Neurosurgery, Penn State Hershey Medical Center, University Dr (H110), 850, Hershey, PA, 17033, USA
| | - Ian A Simpson
- Department of Neural and Behavioral Sciences, Penn State Hershey Medical Center, Hershey, PA, USA
| | | | - Richard Allen
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | | | - David Rye
- Department of Neurology, Emory University, Atlanta, GA, USA
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Ma TT, Yang Z, Zhu S, Zhao JH, Li Y, Sun FY, Zhao N, Xiong ZY, Xiong ZB, Dong J. Pramipexole in peritoneal dialysis patients with restless legs syndrome (RLS): a protocol for a multicentre double-blind randomised controlled trial. BMJ Open 2020; 10:e033815. [PMID: 32075834 PMCID: PMC7045231 DOI: 10.1136/bmjopen-2019-033815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Restless legs syndrome (RLS) is a common neurological sensorimotor disorder among patients with end stage renal disease. This clinical trial aimed to provide evidence on the efficacy and safety of pramipexole in patients with uremic RLS receiving peritoneal dialysis (PD). METHODS AND ANALYSIS This is a 12-week, multicentre, randomised, double-blind, placebo-controlled clinical trial. In total, 104 patients with uremic RLS receiving PD will be enrolled from four hospitals and randomly assigned in a 1:1 ratio to either placebo or pramipexole. We will determine the efficacy of pramipexole in the improvement of International RLS Study Group Rating Scale as the primary outcome, while responder rates for other RLS scales at week 12, change from baseline to week 12 for psychological status, sleep disorder and quality of life and blood pressure represent the secondary outcomes. ETHICS AND DISSEMINATION The study was approved by the ethics committees of Peking University First Hospital, Xinqiao hospital of Army Medical University, Cangzhou Center Hospital and Peking University Shenzhen Hospital. The results will be disseminated in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03817554.
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Affiliation(s)
- Tian-Tian Ma
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Zhikai Yang
- Nephrology, Peking University First Hospital, Beijing, China
| | - Sainan Zhu
- Department of Statistics, Peking University First Hospital, Beijing, China
| | - Jing-Hong Zhao
- Renal Division, Department of Medicine, Xinqiao Hospital, Chongqing, Sichuan, China
| | - Yi Li
- Renal Division, Department of Medicine, Xinqiao Hospital, Chongqing, Sichuan, China
| | - Fu-Yun Sun
- Renal Division, Department of Medicine, Cang Zhou Central Hospital, Cang Zhou, China
| | - Nan Zhao
- Renal Division, Department of Medicine, Cang Zhou Central Hospital, Cang Zhou, China
| | - Zu-Ying Xiong
- Renal Division, Department of Medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Zi-Bo Xiong
- Renal Division, Department of Medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jie Dong
- Peking University First Hospital, Beijing, China
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Ostroumova T, Ostroumova O, Filippova Y, Parfenov V. Drug-induced restless legs syndrome. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:129-135. [DOI: 10.17116/jnevro2020120041129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hankin C, Lee D, Garcia-Borreguero D, Wang Z. Increased Risk for New-Onset Psychiatric Adverse Events in Patients With Newly Diagnosed Primary Restless Legs Syndrome Who Initiate Treatment With Dopamine Agonists: A Large-Scale Retrospective Claims Matched-Cohort Analysis. J Clin Sleep Med 2019; 15:1225-1232. [PMID: 31538593 PMCID: PMC6760417 DOI: 10.5664/jcsm.7908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 04/14/2019] [Accepted: 04/16/2019] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Published literature documents increased risk for psychiatric adverse events (P-AEs) following dopamine agonist (DA) initiation for treatment of primary restless legs syndrome (RLS). We examined the association between DA initiation and subsequent new-onset P-AEs among patients with a new diagnosis of RLS who had no history of psychiatric disorder or DA use. METHODS Selected were adults (age 18 years or older) enrolled through United States employer-sponsored plans and Medicare Advantage from 7/1/2008-12/31/2014, with ≥ 2 years of claims data preceding their first RLS diagnosis ("preindex period"). Excluded were those with psychiatric diagnoses (International Classification of Diseases, Ninth Revision [ICD-9] 290-319) or DA use during the preindex period, and those with possible secondary RLS. Patients who initiated (DA+) versus did not initiate (DA-) DAs were matched 1:1 on age at index RLS diagnosis, sex, geographic region, and employment status, and preindex period comorbid illness burden and number of non-DA drug fills. Using a validated ICD-9-based severity-of-illness psychiatric disorder classification system, we compared likelihoods of new-onset P-AEs between matched pairs during parallel follow-up periods. RESULTS Identified were 889 matched pairs. Compared with their DA- counterparts, DA+ patients were nearly two times more likely to experience development of any P-AE (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.31-2.24, P < .0001); and similarly more likely to experience the development of a severe (OR 1.68, 95% CI 1.03-2.86, P = .04), moderately severe (OR 1.63, 95% CI 1.17-2.29, P = .004), or mild (OR 1.72, 95% CI 1.12-2.65, P = .01) P-AE. CONCLUSIONS Compared to DA- matched control patients, patients in whom RLS was newly diagnosed and who initiated de novo DAs demonstrated significantly increased risk for subsequent development of P-AEs of any severity. CITATION Hankin C, Lee D, Garcia-Borreguero D, Wang Z. Increased risk for new-onset psychiatric adverse events in patients with newly diagnosed primary restless legs syndrome who initiate treatment with dopamine agonists: a large-scale retrospective claims matched-cohort analysis. J Clin Sleep Med. 2019;15(9): 1225-1232.
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Affiliation(s)
| | - Daniel Lee
- Baptist Health Medical Group, Richmond, Kentucky
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de Biase S, Pellitteri G, Gigli GL, Valente M. Advancing synthetic therapies for the treatment of restless legs syndrome. Expert Opin Pharmacother 2019; 20:1971-1980. [DOI: 10.1080/14656566.2019.1654997] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Stefano de Biase
- Neurology Unit, Department of Neurosciences, University Hospital of Udine, Udine, Italy
| | - Gaia Pellitteri
- Neurology Unit, Department of Neurosciences, University Hospital of Udine, Udine, Italy
| | - Gian Luigi Gigli
- Neurology Unit, Department of Neurosciences, University Hospital of Udine, Udine, Italy
- DMIF, University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Neurology Unit, Department of Neurosciences, University Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine Medical School, Udine, Italy
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Sundaresan S, Migden MR, Silapunt S. Treatment of Leg Veins for Restless Leg Syndrome: A Retrospective Review. Cureus 2019; 11:e4368. [PMID: 31192073 PMCID: PMC6551200 DOI: 10.7759/cureus.4368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Restless leg syndrome (RLS) and chronic venous insufficiency (CVI) share similar circadian timings and epidemiological characteristics. OBJECTIVE The objective of the study was to investigate whether treating superficial venous reflux (SVR) improves the RLS severity in patients with CVI and whether there is an association of the RLS severity with the number of refluxed veins. MATERIALS AND METHODS Patients with RLS and duplex ultrasound-proven SVR were identified from a database of 134 patients. All patients underwent endovenous radiofrequency ablation and ultrasound-guided foam sclerotherapy. International RLS (IRLS) rating scale questionnaires were reviewed to assess pre- and post-intervention RLS status. RESULTS Thirty-five patients were identified. The average baseline IRLS score was 19.83 (moderate RLS) and improved to 7.89 (mild RLS) after treatment (p < .0001), corresponding to 63% decrease in symptoms. Ten patients (29%) had a follow-up score of 0, indicating complete relief of RLS symptoms. Twenty patients (57%) had decreased IRLS scores of 10 points or more (i.e. 1 grade level of severity). Six patients had no improvement. There was no association of the RLS severity with the number of refluxed veins. CONCLUSION The study found that correcting SVR improves RLS symptoms, suggesting an association between CVI and RLS. Venous ultrasound study and intervention should be considered for potential patients.
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Affiliation(s)
| | - Michael R Migden
- Dermatology, Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Sirunya Silapunt
- Dermatology, University of Texas McGovern Medical School, Houston, USA
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A Case-Based Approach to the Identification and Treatment of Sleep Disorders in Neurology Practice. CURRENT SLEEP MEDICINE REPORTS 2019. [DOI: 10.1007/s40675-019-0135-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
BACKGROUND Restless legs syndrome (RLS) is a common neurologic disorder that is associated with peripheral iron deficiency in a subgroup of patients. It is unclear whether iron therapy is effective treatment for RLS. OBJECTIVES To evaluate the efficacy and safety of oral or parenteral iron for the treatment of restless legs syndrome (RLS) when compared with placebo or other therapies. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycNFO, and CINAHL for the time period January 1995 to September 2017. We searched reference lists for additional published studies. We searched Clinicaltrials.gov and other clinical trial registries (September 2017) for ongoing or unpublished studies. 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 independently extracted data and assessed trial quality, with discussion to reach consensus in the case of any disagreement. The primary outcome considered in this review was restlessness or unpleasant sensations, as experienced subjectively by the patient. We combined treatment/control differences in the outcomes across studies using random-effects meta-analyses. We analysed continuous data using mean differences (MDs) where possible and performed standardised mean difference (SMD) analyses when different measurements were used across studies. We calculated risk ratios (RRs) for dichotomous data using the Mantel-Haenszel method and 95% confidence intervals (CIs). We analysed study heterogeneity using the I2 statistic. We used standard methodological procedures expected by Cochrane. We performed GRADE analysis using GRADEpro. MAIN RESULTS We identified and included 10 studies (428 total participants, followed for 2-16 weeks) in this review. Our primary outcome was restlessness or uncomfortable leg sensations, which was quantified using the International Restless Legs Scale (IRLS) (range, 0 to 40) in eight trials and a different RLS symptom scale in a ninth trial. Nine studies compared iron to placebo and one study compared iron to a dopamine agonist (pramipexole). The possibility for bias among the trials was variable. Three studies had a single element with high risk of bias, which was lack of blinding in two and incomplete outcome data in one. All studies had at least one feature resulting in unclear risk of bias.Combining data from the seven trials using the IRLS to compare iron and placebo, use of iron resulted in greater improvement in IRLS scores (MD -3.78, 95% CI -6.25 to -1.31; I2= 66%, 7 studies, 345 participants) measured 2 to 12 weeks after treatment. Including an eighth study, which measured restlessness using a different scale, use of iron remained beneficial compared to placebo (SMD -0.74, 95% CI -1.26 to -0.23; I2 = 80%, 8 studies, 370 participants). The GRADE assessment of certainty for this outcome was moderate.The single study comparing iron to a dopamine agonist (pramipexole) found a similar reduction in RLS severity in the two groups (MD -0.40, 95% CI -5.93 to 5.13, 30 participants).Assessment of secondary outcomes was limited by small numbers of trials assessing each outcome. Iron did not improve quality of life as a dichotomous measure (RR 2.01, 95% CI 0.54 to 7.45; I2=54%, 2 studies, 39 participants), but did improve quality of life measured on continuous scales (SMD 0.51, 95% CI 0.15 to 0.87; I2= 0%, 3 studies, 128 participants), compared to placebo. Subjective sleep quality was no different between iron and placebo groups (SMD 0.19, 95% CI -0.18 to 0.56; I2 = 9%, 3 studies, 128 participants), nor was objective sleep quality, as measured by change in sleep efficiency in a single study (-35.5 +/- 92.0 versus -41.4 +/- 98.2, 18 participants). Periodic limb movements of sleep were not significantly reduced with iron compared to placebo ( SMD -0.19, 95% CI -0.70 to 0.32; I2 = 0%, 2 studies, 60 participants). Iron did not improve sleepiness compared to placebo, as measured on the Epworth Sleepiness Scale (data not provided, 1 study, 60 participants) but did improve the daytime tiredness item of the RLS-6 compared to placebo (least squares mean difference -1.5, 95% CI -2.5 to -0.6; 1 study, 110 participants). The GRADE rating for secondary outcomes ranged from low to very low.Prespecified subgroup analyses showed more improvement with iron in those trials studying participants on dialysis. The use of low serum ferritin levels as an inclusion criteria and the use or oral versus intravenous iron did not show significant subgroup differences.Iron did not result in significantly more adverse events than placebo (RR 1.48, 95% CI 0.97 to 2.25; I2=45%, 6 studies, 298 participants). A single study reported that people treated with iron therapy experienced fewer adverse events than the active comparator pramipexole. AUTHORS' CONCLUSIONS Iron therapy probably improves restlessness and RLS severity in comparison to placebo. Iron therapy may not increase the risk of side effects in comparison to placebo. We are uncertain whether iron therapy improves quality of life in comparison to placebo. Iron therapy may make little or no difference to pramipexole in restlessness and RLS severity, as well as in the risk of adverse events. The effect on secondary outcomes such as quality of life, daytime functioning, and sleep quality, the optimal timing and formulation of administration, and patient characteristics predicting response require additional study.
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Affiliation(s)
- Lynn M Trotti
- Emory University School of MedicineDepartment of Neurology12 Executive Park Drive NEAtlantaUSA30329
| | - Lorne A Becker
- SUNY Upstate Medical UniversityDepartment of Family Medicine475 Irving AveSuite 200SyracuseNew YorkUSA13210
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Ferré S, Quiroz C, Rea W, Guitart X, García-Borreguero D. Adenosine mechanisms and hypersensitive corticostriatal terminals in restless legs syndrome. Rationale for the use of inhibitors of adenosine transport. PHARMACOLOGY OF RESTLESS LEGS SYNDROME (RLS) 2019; 84:3-19. [DOI: 10.1016/bs.apha.2018.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Garbazza C, Manconi M. Management Strategies for Restless Legs Syndrome/Willis-Ekbom Disease During Pregnancy. Sleep Med Clin 2018; 13:335-348. [PMID: 30098751 DOI: 10.1016/j.jsmc.2018.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Restless legs syndrome/Willis-Ekbom disease is a common disorder during pregnancy that may significantly impact on the health of affected women, leading to negative consequences in the short and long term. An accurate diagnosis helps to recognize the syndrome and choose the optimal therapeutic strategy, based on the characteristics and needs of the patient. This article summarizes the main treatment options recommended by the consensus clinical guidelines of the International Restless Legs Syndrome Study Group and provides a short guide to the management of restless leg syndrome during pregnancy in clinical practice.
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Affiliation(s)
- Corrado Garbazza
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano (EOC), Via Tesserete 46, Lugano CH-6903, Switzerland.
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano (EOC), Via Tesserete 46, Lugano CH-6903, Switzerland
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Garcia-Borreguero D, Cano-Pumarega I, Marulanda R. Management of treatment failure in restless legs syndrome (Willis-Ekbom disease). Sleep Med Rev 2018; 41:50-60. [DOI: 10.1016/j.smrv.2018.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 12/16/2017] [Accepted: 01/02/2018] [Indexed: 10/18/2022]
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Kwatra V, Khan MA, Quadri SA, Cook TS. Differential Diagnosis and Treatment of Restless Legs Syndrome: A Literature Review. Cureus 2018; 10:e3297. [PMID: 30443467 PMCID: PMC6235628 DOI: 10.7759/cureus.3297] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/13/2018] [Indexed: 01/18/2023] Open
Abstract
Restless legs syndrome (RLS) is a chronic neurological disorder affecting a growing number of people. Patients describe an irresistible urge to move their lower limbs in times of immobility. Due to its vague symptoms and similarity to other disorders, it has become increasingly difficult for primary care clinicians to properly diagnose and manage RLS. As a result, patients with RLS are routinely misdiagnosed and continue their lives without proper management. This literature review examines the current understanding of the disorder, provides key points to assist clinicians in differentiating RLS from similar disorders, and explores recently updated evidence-based guidelines for the effective management of RLS.
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Affiliation(s)
- Vishal Kwatra
- Internal Medicine, St. Vincent Charity Medical Center, Cleveland, USA
| | - Muhammad Adnan Khan
- Neurosciences & Neurology, California Institute of Neurosciences, Thousand Oaks, USA
| | - Syed A Quadri
- Neurosurgery, California Institute of Neurosciences, Thousand Oaks, USA
| | - Trevor S Cook
- Emergency, Palacios Community Hospital, Palacios, USA
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Abstract
Pregnancy often predisposes women to new-onset sleep disturbances, as well as exacerbations of preexisting sleep disorders. The goals of treating perinatal sleep disorders include the promotion of restorative sleep and the benefits it brings to both mother and fetus. The prescribing of any sleep aid in pregnancy must include consideration of the risks and benefits for both the patient and her fetus. Although data on the perinatal use of sleep aids is limited, there may be effects on fetal development, timing and duration of delivery, and postnatal outcomes.
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Affiliation(s)
- Laura P McLafferty
- Department of Psychiatry and Human Behavior, Thomas Jefferson University, Thompson Building, Suite 1652, 1020 Sansom Street, Philadelphia, PA 19107, USA.
| | - Meredith Spada
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O'Hara St., Pittsburgh, PA 15213, USA
| | - Priya Gopalan
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, 3811 O'Hara St., Pittsburgh, PA 15213, USA
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Abstract
PURPOSE OF REVIEW This article provides an update on six sleep-related movement disorders: restless legs syndrome (RLS), periodic limb movement disorder, sleep-related leg cramps, bruxism, rhythmic movement disorder, and propriospinal myoclonus, with an emphasis on RLS. RECENT FINDINGS RLS is a common sensorimotor disorder that impairs quality of life. RLS is frequently comorbid to neurologic, psychiatric, vascular, and inflammatory diseases. Accumulating evidence implicates the pathophysiology of RLS as a state of dopamine dysfunction and iron deficiency that occurs on a background of genetic susceptibility conferred by 6 gene polymorphisms. Multiple treatments approved by the US Food and Drug Administration (FDA) are available. Dopamine agonists and α2δ calcium channel ligands are considered first-line treatments, but these treatments have very different side effect profiles that should be taken into consideration. SUMMARY Sleep-related movement disorders are frequently encountered in clinical practice. For some disorders, particularly RLS and periodic limb movement disorder, our understanding of biology, epidemiology, and treatment is advanced. For others, much work is needed to determine optimal treatment strategies.
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Abstract
PURPOSE OF REVIEW This article provides a clinical approach to the appropriate investigation and diagnosis of sleep disorders commonly seen by neurologists. RECENT FINDINGS Home sleep apnea testing in appropriate situations can replace laboratory polysomnography in many cases of uncomplicated sleep apnea. Multiple sleep latency tests must be performed meticulously and interpreted in the clinical setting to avoid overdiagnoses of narcolepsy. Human leukocyte antigen testing has limited utility in establishing a diagnosis of narcolepsy because a positive test has low specificity. Rapid eye movement (REM) sleep behavior disorder is frequently the first manifestation of an evolving synucleinopathy, and a careful history and neurologic examination are needed to determine other early features of these disorders. SUMMARY A meticulous history from the patient, supplemented by collateral history from an observer, is essential to establishing the diagnosis of sleep disorders. Judicious supplementary use of investigations, such as laboratory polysomnography, home sleep apnea testing, wrist actigraphy, and multiple sleep latency tests, can confirm the correct diagnosis. This article describes an approach to the sleepy patient, the patient with neuromuscular disease and possible sleep-disordered breathing, the patient with restless legs syndrome, and young and older patients with abnormal movements during sleep.
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Edaki O, Danish N, Khawaja IS. An Elderly Woman Who Could Not Stay Asleep. Psychiatr Ann 2018. [DOI: 10.3928/00485713-20180511-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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43
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Abstract
Restless legs syndrome (RLS) is a disorder characterized by an irresistible urge to move the legs during rest, usually accompanied by uncomfortable sensations in the affected extremity or extremities. RLS can manifest at any age but prevalence increases with advancing age. This article describes the symptoms of RLS, associated comorbidities, and how to diagnose and manage RLS.
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44
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Magnitude and duration of acute-exercise intensity effects on symptoms of restless legs syndrome: a pilot study. Sleep Biol Rhythms 2018. [DOI: 10.1007/s41105-018-0158-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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45
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[Sleepiness, continuous positive airway pressure and the obstructive sleep apnea hypopnea syndrome]. Rev Mal Respir 2018; 35:116-133. [PMID: 29454715 DOI: 10.1016/j.rmr.2017.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 04/01/2017] [Indexed: 12/23/2022]
Abstract
Excessive daytime sleepiness is a major symptom in cases of the obstructive sleep apnea-hypopnea syndrome. Most often, it is vastly improved by treatment with continuous positive airway pressure (CPAP). The most effective way to confirm its disappearance is through wakefulness maintenance testing. If residual sleepiness remains, despite CPAP, further diagnostic investigation must be carried out. Firstly, it must be assessed whether the treatment is fully effective (apnea hypopnea index<10/h) by examining flow limitations under treatment (polysomnography) and whether it is sufficiently used (>6h/night). If this is the case, the possibility of other situations responsible for excessive daytime sleepiness must be reviewed and eliminated, whether they are depression, sleep insufficiency, use of intoxicants, obesity, restless legs syndrome, or circadian sleep-wake cycle disorder. If not, the multiple sleep latency tests make it possible to assess sleepiness (latency<8min) and can lead to a diagnosis of central hypersomnia (narcolepsy, idiopathic hypersomnia, hypersomnia due to a medical pathology). In some rare cases (about 6% of patients) investigations will reveal central hypersomnia due to the obstructive sleep apnea-hypopnea syndrome or "lesional" hypersomnia due to intermittent hypoxia. Since 2011, medications treating excessive sleepiness have had marketing authorization only for narcolepsy in France. However, they can be administered by way of derogation to other neurological hypersomnias on prescription by a reference centre or a centre with expertise in hypersomnia.
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46
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Abstract
Restless legs syndrome is a common neurological condition affecting a substantial portion of the population. It can be an idiopathic disorder, or one that is secondary to another cause. Given that the underlying pathophysiology of restless legs syndrome is not well understood, several drug classes have been studied for symptom control. While dopamine agonists have long been the mainstay of first-line treatment for restless legs syndrome, recently, the α2δ ligands have been increasingly used. These agents have proven both efficacious and safe in a number of clinical trials. Additionally, compared with the dopamine agonists, they have been associated with less augmentation, a phenomenon whereby symptoms emerge earlier in the day, become more severe, and may spread to areas of the body previously unaffected. Newer clinical guidelines for restless legs syndrome are increasingly recommending the α2δ ligands as a logical first-choice medication for patients needing drug therapy for symptom control.
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Affiliation(s)
- Michele A Faulkner
- Schools of Pharmacy and Medicine, Creighton University, 2500 California Plaza, Omaha, NE, 68178, USA.
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Ferré S, Quiroz C, Guitart X, Rea W, Seyedian A, Moreno E, Casadó-Anguera V, Díaz-Ríos M, Casadó V, Clemens S, Allen RP, Earley CJ, García-Borreguero D. Pivotal Role of Adenosine Neurotransmission in Restless Legs Syndrome. Front Neurosci 2018; 11:722. [PMID: 29358902 PMCID: PMC5766678 DOI: 10.3389/fnins.2017.00722] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 12/11/2017] [Indexed: 11/13/2022] Open
Abstract
The symptomatology of Restless Legs Syndrome (RLS) includes periodic leg movements during sleep (PLMS), dysesthesias, and hyperarousal. Alterations in the dopaminergic system, a presynaptic hyperdopaminergic state, seem to be involved in PLMS, while alterations in glutamatergic neurotransmission, a presynaptic hyperglutamatergic state, seem to be involved in hyperarousal and also PLMS. Brain iron deficiency (BID) is well-recognized as a main initial pathophysiological mechanism of RLS. BID in rodents have provided a pathogenetic model of RLS that recapitulates the biochemical alterations of the dopaminergic system of RLS, although without PLMS-like motor abnormalities. On the other hand, BID in rodents reproduces the circadian sleep architecture of RLS, indicating the model could provide clues for the hyperglutamatergic state in RLS. We recently showed that BID in rodents is associated with changes in adenosinergic transmission, with downregulation of adenosine A1 receptors (A1R) as the most sensitive biochemical finding. It was hypothesized that A1R downregulation leads to hypersensitive striatal glutamatergic terminals and facilitation of striatal dopamine release. Hypersensitivity of striatal glutamatergic terminals was demonstrated by an optogenetic-microdialysis approach in the rodent with BID, indicating that it could represent a main pathogenetic factor that leads to PLMS in RLS. In fact, the dopaminergic agonists pramipexole and ropinirole and the α2δ ligand gabapentin, used in the initial symptomatic treatment of RLS, completely counteracted optogenetically-induced glutamate release from both normal and BID-induced hypersensitive corticostriatal glutamatergic terminals. It is a main tenet of this essay that, in RLS, a single alteration in the adenosinergic system, downregulation of A1R, disrupts the adenosine-dopamine-glutamate balance uniquely controlled by adenosine and dopamine receptor heteromers in the striatum and also the A1R-mediated inhibitory control of glutamatergic neurotransmission in the cortex and other non-striatal brain areas, which altogether determine both PLMS and hyperarousal. Since A1R agonists would be associated with severe cardiovascular effects, it was hypothesized that inhibitors of nucleoside equilibrative transporters, such as dipyridamole, by increasing the tonic A1R activation mediated by endogenous adenosine, could represent a new alternative therapeutic strategy for RLS. In fact, preliminary clinical data indicate that dipyridamole can significantly improve the symptomatology of RLS.
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Affiliation(s)
- Sergi Ferré
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD, United States
| | - César Quiroz
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD, United States
| | - Xavier Guitart
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD, United States
| | - William Rea
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD, United States
| | - Arta Seyedian
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD, United States
| | - Estefanía Moreno
- Center for Biomedical Research in Neurodegenerative Diseases Network and Department of Biochemistry and Molecular Biomedicine, Faculty of Biology, Institute of Biomedicine of the University of Barcelona, University of Barcelona, Barcelona, Spain
| | - Verònica Casadó-Anguera
- Center for Biomedical Research in Neurodegenerative Diseases Network and Department of Biochemistry and Molecular Biomedicine, Faculty of Biology, Institute of Biomedicine of the University of Barcelona, University of Barcelona, Barcelona, Spain
| | - Manuel Díaz-Ríos
- Department of Anatomy and Neurobiology and Institute of Neurobiology, University of Puerto Rico, San Juan, PR, United States
| | - Vicent Casadó
- Center for Biomedical Research in Neurodegenerative Diseases Network and Department of Biochemistry and Molecular Biomedicine, Faculty of Biology, Institute of Biomedicine of the University of Barcelona, University of Barcelona, Barcelona, Spain
| | - Stefan Clemens
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Richard P Allen
- Center for Restless Legs Study, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
| | - Christopher J Earley
- Center for Restless Legs Study, Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
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48
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Silber MH, Becker PM, Buchfuhrer MJ, Earley CJ, Ondo WG, Walters AS, Winkelman JW. The Appropriate Use of Opioids in the Treatment of Refractory Restless Legs Syndrome. Mayo Clin Proc 2018; 93:59-67. [PMID: 29304922 DOI: 10.1016/j.mayocp.2017.11.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/24/2017] [Accepted: 11/01/2017] [Indexed: 01/18/2023]
Abstract
Restless legs syndrome (RLS) is a distinct disorder, differing from chronic pain in many ways. Refractory RLS is characterized by unresponsiveness to dopamine agonists or alpha-2-delta ligands due to inadequate efficacy, augmentation, or adverse effects. This may result in severely impaired quality of life, profound insomnia, and suicidal depression. Opioid therapy is a mainstay in the management of these patients. This article summarizes the basic science and clinical evidence in support of their use, including the positive result of a large controlled multicenter study of 306 subjects, and outlines an approach to their use in clinical practice. Treatable explanations for RLS refractoriness, such as low iron stores, and other therapeutic options, such as combination therapy, should be considered before prescribing opioids. The agents most commonly used are oxycodone and methadone, but tramadol, codeine, morphine, and hydrocodone can also be considered. Controlled-release medication should be used for evening dosage and short-acting drugs, if needed, during the day. Effective doses are considerably lower than used for chronic pain (oxycodone 10-30 mg daily; methadone 5-20 mg daily) and the risk of opioid use disorder is relatively low. However, sensible precautions should be undertaken, including assessing opioid risk with standard questionnaires, using an opioid contract, using urine drug screens, consulting state prescription drug monitoring programs, and frequent reevaluation of effectiveness and side effects. Opioid use in selected patients with refractory RLS may be life-transforming with favorable risk-benefit ratio.
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Affiliation(s)
- Michael H Silber
- Department of Neurology and Center for Sleep Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
| | - Philip M Becker
- Sleep Medicine Associates of Texas and Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mark J Buchfuhrer
- Department of Psychiatry and Behavioral Science, Stanford School of Medicine, Stanford, CA
| | - Christopher J Earley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William G Ondo
- Methodist Research Institute and Department of Neurology, Weill Cornell Medical School, Houston, TX
| | - Arthur S Walters
- Division of Sleep Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - John W Winkelman
- Department of Psychiatry and Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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49
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Yepes G, Guitart X, Rea W, Newman AH, Allen RP, Earley CJ, Quiroz C, Ferré S. Targeting hypersensitive corticostriatal terminals in restless legs syndrome. Ann Neurol 2017; 82:951-960. [PMID: 29171915 DOI: 10.1002/ana.25104] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/16/2017] [Accepted: 11/16/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The first aim was to demonstrate a previously hypothesized increased sensitivity of corticostriatal glutamatergic terminals in the rodent with brain iron deficiency (BID), a pathogenetic model of restless legs syndrome (RLS). The second aim was to determine whether these putative hypersensitive terminals could constitute a significant target for drugs effective in RLS, including dopamine agonists (pramipexole and ropinirole) and α2 δ ligands (gabapentin). METHODS A recently introduced in vivo optogenetic-microdialysis approach was used, which allows the measurement of the extracellular concentration of glutamate upon local light-induced stimulation of corticostriatal glutamatergic terminals. The method also allows analysis of the effect of local perfusion of compounds within the same area being sampled for glutamate. RESULTS BID rats showed hypersensitivity of corticostriatal glutamatergic terminals (lower frequency of optogenetic stimulation to induce glutamate release). Both hypersensitive and control glutamatergic terminals were significant targets for locally perfused pramipexole, ropinirole, and gabapentin, which significantly counteracted optogenetically induced glutamate release. The use of selective antagonists demonstrated the involvement of dopamine D4 and D2 receptor subtypes in the effects of pramipexole. INTERPRETATION Hypersensitivity of corticostriatal glutamatergic terminals can constitute a main pathogenetic mechanism of RLS symptoms. Selective D4 receptor agonists, by specifically targeting these terminals, should provide a new efficient treatment with fewer secondary effects. Ann Neurol 2017;82:951-960.
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Affiliation(s)
- Gabriel Yepes
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD
| | - Xavier Guitart
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD
| | - William Rea
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD
| | - Amy H Newman
- Medicinal Chemistry Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD
| | - Richard P Allen
- Center for Restless Legs Study, Department of Neurology, Johns Hopkins University, Baltimore, MD
| | - Christopher J Earley
- Center for Restless Legs Study, Department of Neurology, Johns Hopkins University, Baltimore, MD
| | - César Quiroz
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD
| | - Sergi Ferré
- Integrative Neurobiology Section, National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, Baltimore, MD
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50
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Allen RP, Picchietti DL, Auerbach M, Cho YW, Connor JR, Earley CJ, Garcia-Borreguero D, Kotagal S, Manconi M, Ondo W, Ulfberg J, Winkelman JW. Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease in adults and children: an IRLSSG task force report. Sleep Med 2017; 41:27-44. [PMID: 29425576 DOI: 10.1016/j.sleep.2017.11.1126] [Citation(s) in RCA: 170] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 11/09/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Brain iron deficiency has been implicated in the pathophysiology of RLS, and current RLS treatment guidelines recommend iron treatment when peripheral iron levels are low. In order to assess the evidence on the oral and intravenous (IV) iron treatment of RLS and periodic limb movement disorder (PLMD) in adults and children, the International Restless Legs Syndrome Study Group (IRLSSG) formed a task force to review these studies and provide evidence-based and consensus guidelines for the iron treatment of RLS in adults, and RLS and PLMD in children. METHODS A literature search was performed to identify papers appearing in MEDLINE from its inception to July 2016. The following inclusion criteria were used: human research on the treatment of RLS or periodic limb movements (PLM) with iron, sample size of at least five, and published in English. Two task force members independently evaluated each paper and classified the quality of evidence provided. RESULTS A total of 299 papers were identified, of these 31 papers met the inclusion criteria. Four studies in adults were given a Class I rating (one for IV iron sucrose, and three for IV ferric carboxymaltose); only Class IV studies have evaluated iron treatment in children. Ferric carboxymaltose (1000 mg) is effective for treating moderate to severe RLS in those with serum ferritin <300 μg/l and could be used as first-line treatment for RLS in adults. Oral iron (65 mg elemental iron) is possibly effective for treating RLS in those with serum ferritin ≤75 μg/l. There is insufficient evidence to make conclusions on the efficacy of oral iron or IV iron in children. CONCLUSIONS Consensus recommendations based on clinical practice are presented, including when to use oral iron or IV iron, and recommendations on repeated iron treatments. New iron treatment algorithms, based on evidence and consensus opinion have been developed.
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Affiliation(s)
- Richard P Allen
- Department of Neurology, Johns Hopkins University, Hopkins Bayview Medical Center, Baltimore, MD, USA.
| | - Daniel L Picchietti
- University of Illinois College of Medicine at Urbana-Champaign and Carle Foundation Hospital, Urbana, IL, USA
| | - Michael Auerbach
- Department of Medicine, Georgetown University, Washington DC, USA
| | - Yong Won Cho
- Department of Neurology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - James R Connor
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey PA, USA
| | - Christopher J Earley
- Department of Neurology, Johns Hopkins University, Hopkins Bayview Medical Center, Baltimore, MD, USA
| | | | - Suresh Kotagal
- Department of Neurology and the Center for Sleep Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano, Lugano, Switzerland
| | - William Ondo
- Methodist Neurological Institute, Weill Cornell Medical School Houston, TX, USA
| | - Jan Ulfberg
- Sleep Disorders Department, Capio Health Center, Örebro, Sweden
| | - John W Winkelman
- Departments of Psychiatry and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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