Does domperidone potentiate mirtazapine-associated restless legs syndrome?

Relative frequency of drug-induced sleep disorders for 32 antidepressants in a large set of Internet user reviews

STUDY OBJECTIVES

It is known that antidepressant drugs can induce sleep disorders in patients, but little data exist about high or low-risk molecules. The aim was to study the frequency of antidepressant drugs-induced sleep disorders (DISD) by molecule.

METHODS

77,391 patient comments for 32 antidepressant drugs were collected from drug review websites and screened for DISD. Association between drugs and nightmare disorder, restless legs syndrome, sleep paralysis, sleep terrors, sleep-related hallucinations or sleep walking was expressed as relative proportion [proportional reporting ratio (PRR)]. A detailed analysis of the dreams content was also carried out.

RESULTS

Amitriptyline, doxepin, fluvoxamine, mirtazapine, nortriptyline, trazodone, venlafaxine and vilazodone were associated with a greater frequency of DISD compared to other antidepressants. Vilazodone heavily increased the probability of developing 5 of the 6 studied DISD (PRR 3.3 to 19.3) and mirtazapine increased the probability for developing 4 DISD (PRR 2.4 to 6.4). Bupropion and citalopram were associated with lower probabilities for 5 DISD (PRR 0.2 to 0.7). Sentiment analysis showed that patients described disturbing dreams for vilazodone or mirtazapine and strange but less negative dreams for bupropion, citalopram or duloxetine.

CONCLUSIONS

Relative frequencies of sleep disorders were obtained for a vast panel of antidepressant drugs through an original analysis of user's drug reviews on drug rating websites. Our results could guide clinicians in appropriate choice of antidepressant drug for high DISD-risk patients in need of such treatment. These results may however be cautiously taken, considering the uncertain reliability and generalisability of web-based data.

Mirtazapine-associated movement disorders: A literature review

Mirtazapine (MTZ) is an atypical antidepressant approved by the FDA, which mechanism of action involves the antagonism of alpha-2, H1, 5-HT2A, 5-HT2C, and 5-HT3 receptors. In this context, the aim of this literature review is to evaluate the clinical epidemiological profile, pathological mechanisms, and management of MTZ-associated movement disorders (MDs). Relevant reports of six databases were identified and assessed by two reviewers without language restriction. Fifty-two reports containing 179 cases from 20 countries were assessed. The mean age was 57 year (range, 17-85). The majority of the individuals were female (60%) and of European origin. The mean time from MTZ start to symptom onset was 7.54 days; the time from management to MD improvement was within one week in 82.60% of the individuals. The MDs associated with MTZ were 69 restless legs syndrome (RLS), 35 tremors, 10 akathisia (AKT), 9 periodic limb MD, 6 dystonia, 4 rapid eye movement sleep behavior disorders, 3 dyskinesia, 2 parkinsonism, and 1 tic, and in the group not clearly identified, 18 restlessness, 15 hyperkinesis, and 1 extrapyramidal symptom. In the literature, the majority of the reports lack important information about the neurological examination. The management should be the MTZ withdrawal, except in RLS that other options are possible. In AKT, the MTZ should not be rechallenge, and if available, the prescription of a benzodiazepine may reduce recovery time.

Drug-Induced Restless Legs Syndrome

OBJECTIVE

To review the literature on drug-induced restless legs syndrome (DI-RLS).

DATA SOURCES

The review included a search for English-language literature from 1966 to December 2017 in the MEDLINE, PubMed, and Ovid databases using the following search terms: restless legs syndrome (RLS), periodic limb movement, adverse effects, and drug-induced. In addition, background articles on the pathophysiology, etiology, and epidemiology of RLS were retrieved. Bibliographies of relevant articles were reviewed for additional citations.

STUDY SELECTION AND DATA EXTRACTION

All case reports, case series, and review articles of DI-RLS were identified and analyzed. There were only a small number of controlled clinical trials, and most data were from case reports and case series.

RESULTS

Several drugs and drug classes have been implicated in DI-RLS, with antidepressants, antipsychotics, and antiepileptics having the most evidence. In addition, RLS may be linked with a number of disorders or underlying predisposing factors as well.

CONCLUSIONS

The prevalence of RLS is variable and ranges from 3% to 19% in the general population. There are many predisposing factors to RLS, but an emerging body of evidence suggests that there is an association between numerous drugs and RLS.

Mirtazapine provokes periodic leg movements during sleep in young healthy men

STUDY OBJECTIVES

Recent evidence suggests that certain antidepressants are associated with an increase of periodic leg movements (PLMS) that may disturb sleep. So far, this has been shown in patients clinically treated for depression and in cross-sectional studies for various substances, but not mirtazapine. It is unclear whether antidepressants induce the new onset of PLMS or only increase preexisting PLMS, and whether this is a general property of the antidepressant or only seen in depressed patients. We report here the effect of mirtazapine on PLMS in young healthy men.

DESIGN

Open-labeled clinical trial (NCT00878540) including a 3-week preparatory phase with standardized food, physical activity, and sleep-wake behavior, and a 10-day experimental inpatient phase with an adaptation day, 2 baseline days, and 7 days with mirtazapine.

SETTING

Research institute.

PARTICIPANTS

Twelve healthy young (20-25 years) men.

INTERVENTIONS

Seven days of nightly intake (22:00) of 30 mg mirtazapine.

MEASUREMENTS AND RESULTS

Sleep was recorded on 2 drug-free baseline nights, the first 2 drug nights, and the last 2 drug nights. Eight of the 12 subjects showed increased PLMS after the first dose of mirtazapine. Frequency of PLMS was highest on the first drug night and attenuated over the course of the next 6 days. Three subjects reported transient restless legs symptoms.

CONCLUSIONS

Mirtazapine provoked PLMS in 67% of young healthy males. The effect was most pronounced in the first days. The possible role of serotonergic, noradrenergic and histaminergic mechanisms in mirtazapine-induced PLMS is discussed.

Depressive disorders in restless legs syndrome: epidemiology, pathophysiology and management

Epidemiological studies report a 2- to 4-fold risk of a depressive disorder in patients with restless legs syndrome (RLS) compared with healthy controls. The high prevalence rates of depression in RLS indicate an association between the two disorders. Severe sleep disturbance due to the nightly occurrence of RLS symptoms is a common complaint of patients with moderate or severe RLS and may substantially contribute to the emergence of depressive symptoms. Difficulty in the diagnosis of a depressive disorder in patients with RLS may arise from the overlap of symptoms in the two disorders, as sleep-related complaints are frequent both in RLS and depression. The treatment of depression in RLS has some unique aspects, as several antidepressants have been reported to trigger or worsen RLS. To date, no studies have been published regarding the course of depression in untreated and treated patients with RLS. On the other hand, the presence of co-morbid depression can have a substantial impact on the global treatment outcome. In patients with co-morbid moderate/severe depression, antidepressant therapy in parallel with or shortly after commencing RLS treatment is usually necessary. Data from recent trials with dopamine receptor agonists indicate that mild to moderate depressive symptoms are often relieved with improvement of RLS symptoms.

Gender differences in the association between antidepressant use and restless legs syndrome

Contradictory results have been reported for the association between antidepressant use and Restless Legs Syndrome (RLS). Our aim was to clarify the relationship and examine possible gender differences. We interviewed 1,693 veterans receiving primary care from the Cleveland VA Medical Center and obtained prescription drug information from their medical records. Overall, use of an antidepressant was associated with RLS for men (RR = 1.77, CI = 1.26, 2.48) but not for women (RR = 0.79, CI = 0.43, 1.47). Analyses of individual antidepressants revealed an association between RLS and fluoxetine for women (RR = 2.47, CI = 1.33, 4.56), and associations between RLS and citalopram, (RR = 2.09, CI = 1.20, 3.64), paroxetine (RR = 1.97, CI = 1.02, 3.79), and amitriptyline (RR = 2.40, CI = 1.45, 4.00) for men. We conclude that RLS may be associated with antidepressant use, but the association varies by gender and type of antidepressant. Antidepressant use is more strongly associated with RLS in men than in women.

[Restless legs syndrome, periodic limb movements, and psychopharmacology]

Restless legs syndrome (RLS) and the often associated periodic limb movement disorder in sleep (PLMD) frequently occur in the general population as a primary disorder. In addition to organic disease, secondary forms are caused by psychotropic medication. Several antidepressants, antipsychotics, lithium, and opioid withdrawal have been shown to induce or exacerbate RLS and PLMD, while several antiepileptics used as mood stabilizers and some benzodiazepines demonstrate therapeutic potential for treating RLS/PLMD. Systematic or controlled studies for evaluating these side effects still do not exist. Among the antidepressants at higher risk of inducing this disorder are selective serotonin reuptake inhibitors, venlafaxine, and some tetracyclic antidepressants. Under medication with some tricyclic substances, periodic limb movements were observed more often. For some antidepressants with differing transmitter profiles such as bupropion RLS/PLMD ameliorating effects or at least neutral effects (Trazodon, Nortriptylin) have been described in small studies. In case of continued of or newly occurring insomnia a thorough history should be taken to identify a possible RLS/PLMD as an intolerable side effect of treatment. A change in medications should be considered if clinically feasible. In case of RLS/PLMD occurring in psychotic patients switching the antipsychotic and additionally using a second line medication such as antiepileptics or a benzodiazepine should be considered.

Restless legs syndrome as side effect of second generation antidepressants

Although of clinical interest, the question is still not fully answered whether antidepressants (AD) can cause or exacerbate restless legs syndrome (RLS). The literature provides contradictory information. This study addresses this problem for the class of second generation AD. In four neurological offices, all patients treated for the first time with an AD were prospectively observed with regard to the question of whether RLS occurred or pre-existing RLS worsened as a result of the medication. Because initial treatment in the participating offices is mainly executed with "modern" selective AD, the study was restricted to these drugs (fluoxetine, paroxetine, citalopram, sertraline, escitalopram, venlafaxine, duloxetine, reboxetine, and mirtazapine). In 9% of patients, RLS was recorded as a side effect related to the administration of AD. The frequency of this side effect varied among the drugs. The problem is most pronounced with mirtazapine provoking or deteriorating RLS in 28% of patients. By contrast, no case occurred during use of reboxetine. As for the other AD, the rate of newly occurred and deteriorated RLS, ranged from 5% to 10%. Typically, RLS occurred during the initial days of treatment.

Factors potentiating the risk of mirtazapine-associated restless legs syndrome

OBJECTIVE

Mirtazapine is known to often provoke restless legs syndrome (RLS). In this retrospective chart review study, we evaluated the socio-demographic and clinical factors related to mirtazapine-associated RLS.

METHODS

Computerized medical records of 181 patients treated with mirtazapine from May 2004 to October 2007 were reviewed. RLS was identified using the diagnostic criteria of the International RLS Study Group. Socio-demographic and clinical characteristics were gathered, including comorbid physical illness and concomitant medications.

RESULTS

Mirtazapine-associated RLS was observed in 14 patients (8%), and most cases had developed within a few days after starting mirtazapine. Concomitant medication with tramadol, non-opioid analgesics, antihistamine, and dopamine-blocking agents was more frequently prescribed in subjects developing mirtazapine-associated RLS. In logistic regression analysis, concomitant medication with tramadol (odds ratio: 8.61, 95% confidence interval: 1.71-43.49) and dopamine-blocking agents (odds ratio: 4.67, 95% confidence interval: 1.31-16.70) enhanced the risk of mirtazapine-associated RLS.

CONCLUSION

The combined use of mirtazapine with tramadol or dopamine-blocking agents could potentiate the risk of RLS. Clinician should watch carefully for the development of RLS when mirtazapine is administered to patients who are taking tramadol or dopamine-blocking agents.