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Sringean J, Udomsirithamrong O, Bhidayasiri R. Too little or too much nocturnal movements in Parkinson's disease: A practical guide to managing the unseen. Clin Park Relat Disord 2024; 10:100258. [PMID: 38845753 PMCID: PMC11153921 DOI: 10.1016/j.prdoa.2024.100258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/13/2024] [Accepted: 05/21/2024] [Indexed: 06/09/2024] Open
Abstract
Nocturnal and sleep-related motor disorders in people with Parkinson's disease (PD) have a wide spectrum of manifestations and present a complex clinical picture. Problems can arise due to impaired movement ability (hypokinesias), e.g. nocturnal hypokinesia or early-morning akinesia, or to excessive movement (hyperkinesias), e.g. end-of-the-day dyskinesia, parasomnias, periodic limb movement during sleep and restless legs syndrome. These disorders can have a significant negative impact on the sleep, daytime functional ability, and overall quality of life of individuals with PD and their carers. The debilitating motor issues are often accompanied by a combination of non-motor symptoms, including pain and cramping, which add to the overall burden. Importantly, nocturnal motor disorders encompass a broader timeline than just the period of sleep, often starting in the evening, as well as occurring throughout the night and on awakening, and are not just limited to problems of insomnia or sleep fragmentation. Diagnosis can be challenging as, in many cases, the 'gold standard' assessment method is video polysomnography, which may not be available in all settings. Various validated questionnaires are available to support evaluation, and alternative approaches, using wearable sensors and digital technology, are now being developed to facilitate early diagnosis and monitoring. This review sets out the parameters of what can be considered normal nocturnal movement and describes the clinical manifestations, usual clinical or objective assessment methods, and evidence for optimal management strategies for the common nocturnal motor disorders that neurologists will encounter in people with PD in their clinical practice.
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Affiliation(s)
- Jirada Sringean
- Chulalongkorn Centre of Excellence for Parkinson’s Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Ornanong Udomsirithamrong
- Chulalongkorn Centre of Excellence for Parkinson’s Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson’s Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
- The Academy of Science, The Royal Society of Thailand, Bangkok 10330, Thailand
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Pellitteri G, Versace S, Merlino G, Nilo A, Gigli GL, Valente M. A comprehensive update on the ADMET considerations for α2δ calcium channel ligand medications for treating restless legs syndrome. Expert Opin Drug Metab Toxicol 2024; 20:133-142. [PMID: 38482850 DOI: 10.1080/17425255.2024.2329738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Restless legs syndrome/Willis-Ekbom disease (RLS/WED) is a sleep-related sensory-motor disorder associated with poor sleep quality and impaired daily functioning. In patients affected by chronic RLS/WED, a pharmacological therapy is recommended. International guidelines suggest to start the treatment with a α2δ calcium channel ligand in most cases, unless contraindicated. AREAS COVERED The present review is based on an extensive Internet and PubMed search from 1986 to 2024. Our purpose is to describe the absorption, distribution, metabolism, and toxicology (ADMET) of the α2δ ligands, with common consideration for the therapeutic class, specificities of different compounds, efficacy, and safety in relation to other treatment options. EXPERT OPINION α2δ ligands are quite similar in their ADMET profiles, sharing most of the pharmacokinetics and potential adverse effects. However, we highlight the linear kinetic of gabapentin enacarbil and pregabalin, differently from gabapentin. α2δ ligands are safe and effective for the treatment of RLS/WED. Additional benefits can be obtained in comorbid insomnia, chronic pain syndromes, history of impulse control disorder, and comorbid anxiety. The use of α2δ ligands is associated with poor risk of augmentation. We still need new long-term safe and effective treatments, which could be developed along with our knowledge of RLS/WED pathophysiology.
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Affiliation(s)
- Gaia Pellitteri
- Clinical Neurology Unit, Udine University Hospital, Udine, Italy
| | - Salvatore Versace
- Clinical Neurology Unit, Udine University Hospital, Udine, Italy
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology Unit, Udine University Hospital, Udine, Italy
| | - Annacarmen Nilo
- Clinical Neurology Unit, Udine University Hospital, Udine, Italy
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Gian Luigi Gigli
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, Udine University Hospital, Udine, Italy
- Department of Medicine (DMED), University of Udine, Udine, Italy
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Grieve AP. Probability of success and group sequential designs. Pharm Stat 2024; 23:185-203. [PMID: 37916276 DOI: 10.1002/pst.2346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 08/11/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
In this article, I extend the use of probability of success calculations, previously developed for fixed sample size studies to group sequential designs (GSDs) both for studies planned to be analyzed by standard frequentist techniques or Bayesian approaches. The structure of GSDs lends itself to sequential learning which in turn allows us to consider how knowledge about the result of an interim analysis can influence our assessment of the study's probability of success. In this article, I build on work by Temple and Robertson who introduced the idea of conditional probability of success, an idea which I also treated in a recent monograph.
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Affiliation(s)
- Andrew P Grieve
- Centre for Excellence in Statistical Innovation, UCB Pharma, Berkshire, UK
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Khan M. Restless Legs Syndrome and Other Common Sleep-Related Movement Disorders. Continuum (Minneap Minn) 2023; 29:1130-1148. [PMID: 37590826 DOI: 10.1212/con.0000000000001269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVE This article reviews common sleep-related movement disorders, including their clinical description, epidemiology, pathophysiology (if known), and evaluation and management strategies. This article will provide the reader with a good foundation for approaching concerns that are suggestive of sleep-related movement disorders to properly evaluate and manage these conditions. LATEST DEVELOPMENTS α2δ Ligands, such as gabapentin enacarbil, can be used for the initial treatment of restless legs syndrome (RLS) or in those who cannot tolerate, or have developed augmentation to, dopamine agonists. Another option is the rotigotine patch, which has a 24-hour treatment window and may be beneficial for those who have developed augmentation with short-acting dopamine agonists. IV iron can improve RLS symptoms even in those whose serum ferritin level is between 75 ng/mL and 100 ng/mL. At serum ferritin levels greater than 75 ng/mL, oral iron will likely have minimal absorption or little effect on the improvement of RLS. Research has found an association between RLS and cardiovascular disease, particularly in people who have periodic limb movements of sleep. ESSENTIAL POINTS RLS is the most common sleep-related movement disorder. Its pathophysiology is likely a combination of central iron deficiency, dopamine overproduction, and possibly cortical excitation. Treatment includes oral or IV iron. Dopaminergic medications can be very effective but often lead to augmentation, which limits their long-term use. Other sleep-related movement disorders to be aware of are sleep-related rhythmic movement disorder, nocturnal muscle cramps, sleep-related propriospinal myoclonus, sleep bruxism, and benign myoclonus of infancy.
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Nilles C, Amorelli G, Pringsheim TM, Martino D. "Unvoluntary" Movement Disorders: Distinguishing between Tics, Akathisia, Restless Legs, and Stereotypies. Semin Neurol 2023; 43:123-146. [PMID: 36854394 DOI: 10.1055/s-0043-1764164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Tics, stereotypies, akathisia, and restless legs fall at different places on the spectrum of discrete, unwanted and potentially disabling motor routines. Unlike tremor, chorea, myoclonus, or dystonia, this subgroup of abnormal movements is characterized by the subject's variable ability to inhibit or release undesired motor patterns on demand. Though it may be sometimes clinically challenging, it is crucial to distinguish these "unvoluntary" motor behaviors because secondary causes and management approaches differ substantially. To this end, physicians must consider the degree of repetitiveness of the movements, the existence of volitional control, and the association with sensory symptoms, or cognitive-ideational antecedent. This review aims to summarize the current existing knowledge on phenomenology, diagnosis, and treatment of tics, stereotypies, akathisia, and restless leg syndrome.
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Affiliation(s)
- Christelle Nilles
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gabriel Amorelli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tamara M Pringsheim
- Department of Clinical Neurosciences, Psychiatry, Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Mathison Centre for Mental Health Research and Education, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Davide Martino
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Mathison Centre for Mental Health Research and Education, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Zeineddine S, Undevia NS. Movement Disorders. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_18] [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: 11/28/2022]
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Bae H, Cho YW, Kim KT, Allen RP, Earley CJ. The Safety and Efficacy of Pregabalin Add-on Therapy in Restless Legs Syndrome Patients. Front Neurol 2021; 12:786408. [PMID: 34912291 PMCID: PMC8666621 DOI: 10.3389/fneur.2021.786408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/20/2021] [Indexed: 12/04/2022] Open
Abstract
Pregabalin is increasingly being used as a first-line treatment for symptomatic control of restless legs syndrome (RLS). This study aimed to evaluate the efficacy and safety of pregabalin as add-on therapy in RLS patients already taking dopamine agonists (DA) but still in need of further management. Patients with idiopathic RLS were enrolled, and all had already been prescribed DA for at least 3 months but still had either persistent symptoms, side effects, or comorbid insomnia. An initial dose of 75 mg pregabalin was begun, adjusted as needed, and maintained at a stable dose for 4 weeks, followed by observation for a total of 8 weeks. RLS symptoms and insomnia scores were evaluated before and after add-on pregabalin treatment. Patients were monitored for side effects that could be attributed to pregabalin. A total of 32 RLS patients were enrolled, and 20 subjects remained until the endpoint. After the pregabalin add-on, the mean IRLS score showed significant improvement compared to the baseline (p < 0.001). The insomnia severity index score also improved (p = 0.036), and no serious adverse effects were observed. Our preliminary data suggests the potential for pregabalin as an add-on therapy to DA with regards to both efficacy and safety in patients who have inadequate RLS improvement.
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Affiliation(s)
- Hyoeun Bae
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Yong Won Cho
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Richard P Allen
- Department of Neurology, Hopkins Bayview Medical Center, Johns Hopkins University, Baltimore, MD, United States
| | - Christopher J Earley
- Department of Neurology, Hopkins Bayview Medical Center, Johns Hopkins University, Baltimore, MD, United States
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Zhou X, Du J, Liang Y, Dai C, Zhao L, Liu X, Tan C, Mo L, Chen L. The Efficacy and Safety of Pharmacological Treatments for Restless Legs Syndrome: Systemic Review and Network Meta-Analysis. Front Neurosci 2021; 15:751643. [PMID: 34764852 PMCID: PMC8576256 DOI: 10.3389/fnins.2021.751643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/29/2021] [Indexed: 01/08/2023] Open
Abstract
Although various drugs are currently used for restless legs syndrome (RLS) in clinic, selecting appropriate drugs for patients is difficult. This network meta-analysis (NMA) aimed to compare the efficacy and safety of different drugs. After literature searching and screening, 46 trials, including 10,674 participants are included in this NMA. The pooled results showed that, compared with placebo, only levodopa is inefficient to relieve symptoms of RLS. Cabergoline decreases IRLS scores to the greatest extent among all drugs (MD −11.98, 95% CI −16.19 to −7.78). Additionally, pramipexole is superior to ropinirole in alleviating symptoms of RLS (MD −2.52, 95% CI −4.69 to −0.35). Moreover, iron supplement alleviates RLS symptoms significantly compared with placebo in patient with iron deficiency (MD −5.15, 95% CI −8.99 to −1.31), but not for RLS patients with normal serum ferritin level (MD −2.22, 95% CI −6.99 to 2.56). For primary RLS, these drugs are also effective, while there is insufficient data to analyze drug efficacy in secondary RLS. We analyzed risk of common adverse effects of drugs including nausea, somnolence, fatigue, headache and nasopharyngitis. Alpha-2-delta ligands and DAs are favorable choices for both primary and secondary RLS because of their significant efficacy and good tolerability. Iron supplement can significantly alleviate symptoms of RLS patients with iron deficiency than placebo. We recommend gabapentin, gabapentin enacarbil, and pregabalin for clinicians for first consideration mainly because that they rarely cause augmentation. Oxycodone-naloxone could be considered in patients with severe or very severe RLS who failed in treatment with above drugs.
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Affiliation(s)
- Xuan Zhou
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Juncong Du
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Liang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chengcheng Dai
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lili Zhao
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Changhong Tan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lijuan Mo
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lifen Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Sieminski M, Skrzypek-Czerko M, Chełminiak Ł. Therapy satisfaction and willingness-to-pay in Polish patients with restless legs syndrome. Sleep Breath 2021; 26:839-846. [PMID: 34333733 PMCID: PMC9130188 DOI: 10.1007/s11325-021-02440-x] [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: 05/08/2021] [Revised: 06/26/2021] [Accepted: 07/13/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Restless legs syndrome (RLS) is a serious burden for patients which can be measured in economic terms by assessing the money spent on therapy and the willingness to pay. The aim of this study was to assess whether or not patients feel satisfied with the therapy relative to the money they spent on the treatment, and to assess patients' willingness to pay for therapy that fully eliminates all RLS symptoms. METHODS Adult subjects with RLS confirmed by actual international consensus criteria, a positive RLS-Diagnostic Index (RLS-DI) score, and clinical examinations and observations were assessed to generate a disease severity index. An original set of questions was used to collect data on patient satisfaction with therapy and their willingness to pay. RESULTS Among 100 subjects, 27% were not satisfied with therapy; this subgroup was characterized by lower indices of severity of the disease. Patients spent approximately 3% of their income in treating RLS. They are willing to pay up to 8.3% of their income to eliminate symptoms. CONCLUSIONS The cost of RLS therapy is a significant part of patient expenditure. Nevertheless, RLS may at times remain so troublesome for patients that they are willing to spend more on therapy to eliminate symptoms.
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Affiliation(s)
- Mariusz Sieminski
- Department of Emergency Medicine, Medical University of Gdansk, Smoluchowskiego 17 , 80-214, Gdansk, Poland.
| | - Marcelina Skrzypek-Czerko
- Department of Neurological-Psychiatric Nursing, Medical University of Gdansk, Skłodowskiej-Curie 3a, 80-210, Gdansk, Poland
| | - Łukasz Chełminiak
- Department of Cardiology, Regional Hospital Grudziadz, Rydygiera 15/17, 86-300, Grudziadz, Poland
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Mc Carthy CE. Sleep Disturbance, Sleep Disorders and Co-Morbidities in the Care of the Older Person. Med Sci (Basel) 2021; 9:medsci9020031. [PMID: 34063838 PMCID: PMC8162526 DOI: 10.3390/medsci9020031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 01/14/2023] Open
Abstract
Sleep complaints can be both common and complex in the older patient. Their consideration is an important aspect of holistic care, and may have an impact on quality of life, mortality, falls and disease risk. Sleep assessment should form part of the comprehensive geriatric assessment. If sleep disturbance is brought to light, consideration of sleep disorders, co-morbidity and medication management should form part of a multifaceted approach. Appreciation of the bi-directional relationship and complex interplay between co-morbidity and sleep in older patients is an important element of patient care. This article provides a brief overview of sleep disturbance and sleep disorders in older patients, in addition to their association with specific co-morbidities including depression, heart failure, respiratory disorders, gastro-oesophageal reflux disease, nocturia, pain, Parkinson's disease, dementia, polypharmacy and falls. A potential systematic multidomain approach to assessment and management is outlined, with an emphasis on non-pharmacological treatment where possible.
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Affiliation(s)
- Christine E. Mc Carthy
- Department of Geriatric Medicine, University Hospital Galway, Galway, Ireland;
- HRB-Clinical Research Facility, National University of Ireland, Galway, Co., Galway, Ireland
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Lv Q, Wang X, Asakawa T, Wang XP. Pharmacologic Treatment of Restless Legs Syndrome. Curr Neuropharmacol 2021; 19:372-382. [PMID: 33380302 PMCID: PMC8033969 DOI: 10.2174/1570159x19666201230150127] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/24/2020] [Accepted: 12/19/2020] [Indexed: 01/14/2023] Open
Abstract
Restless legs syndrome (RLS)/Willis-Ekbom disease is a neurologic disorder characterized by a strong desire to move when at rest (usually in the evening) and paraesthesia in their lower legs. The most widely used therapies for first-line treatment of RLS are dopaminergic drugs; however, their long-term use can lead to augmentation. α2δ Ligands, opioids, iron, glutamatergic drugs, adenosine, and sleep aids have been investigated as alternatives. The pathogenesis of RLS is not well understood. Despite the efficacy of dopaminergic drugs in the treatment of this disorder, unlike in Parkinson's disease dopaminergic cell loss in the substantia nigra has not been observed in RLS. The etiology of RLS is likely complex, involving multiple neural pathways. RLS-related genes identified in genome-wide association studies can provide insight into the mechanistic basis and pathophysiology of RLS. Here we review the current treatments and knowledge of the mechanisms underlying RLS.
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Affiliation(s)
| | | | - Tetsuya Asakawa
- Address correspondence to these authors at the Department of Neurology, TongRen Hospital, Shanghai Jiao Tong University School of Medicine, No.1111 Xianxia Road, 200336, Shanghai, China; Tel: +86-021-52039999-72223; Fax: +86-021-52039999-72223; E-mail: and Department of Neurosurgery, Hamamatsu University School of Medicine, Handayama, 1-20-1, Higashi-ku, Hamamatsu-city, Shizuoka 431-3192, Japan; Tel: + 81-53-435-2283; Fax: + 81-53-435-2282;, E-mail:
| | - Xiao Ping Wang
- Address correspondence to these authors at the Department of Neurology, TongRen Hospital, Shanghai Jiao Tong University School of Medicine, No.1111 Xianxia Road, 200336, Shanghai, China; Tel: +86-021-52039999-72223; Fax: +86-021-52039999-72223; E-mail: and Department of Neurosurgery, Hamamatsu University School of Medicine, Handayama, 1-20-1, Higashi-ku, Hamamatsu-city, Shizuoka 431-3192, Japan; Tel: + 81-53-435-2283; Fax: + 81-53-435-2282;, E-mail:
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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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Ghorayeb I. Idiopathic restless legs syndrome treatment: Progress and pitfalls? PHARMACOLOGY OF RESTLESS LEGS SYNDROME (RLS) 2019; 84:207-235. [DOI: 10.1016/bs.apha.2019.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Restless Legs Syndrome and Other Movement Disorders of Sleep-Treatment Update. Curr Treat Options Neurol 2018; 20:55. [PMID: 30411165 DOI: 10.1007/s11940-018-0540-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review article is to summarize and discuss the recent advances in the treatment of restless legs syndrome (RLS), as well as REM sleep behavior disorder (RBD), and periodic leg movement disorder (PLMD). RECENT FINDINGS Traditionally, dopaminergic therapy has been considered the sole option for first-line treatment of RLS due to their impressive acute efficacy. Dopamine agonists such as oral pramipexole and ropinirole, as well as transdermal rotigotine are all effective treatment options. However, augmentation of the RLS symptoms is a major limitation of oral dopaminergic therapy. Recently, gabapentinoid agents such as gabapentin enacarbil and pregabalin have shown comparable short-term efficacy to dopaminergics with lower risk of augmentation of the RLS symptoms. Recent evidence on the efficacy of oxycodone-naloxone in treatment-resistant RLS provides an additional therapeutic avenue. The increasing understanding of the role of iron in RLS pathophysiology has led to new options in iron supplementation therapy in RLS, including treatment with ferric carboxymaltose. With emerging evidence of augmentation being a side effect specific to dopaminergic treatment, gabapentinoids are considered a safer option as initial treatment. In severe refractory RLS, oxycodone-naloxone can be used. If iron stores are low, IV iron formulations should be the initial treatment choice. New treatment options are needed to address issues with current therapies.
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Abstract
Treatment of restless legs syndrome (RLS) must only be considered after a definite positive diagnosis. The RLS phenotype must be characterised precisely, iron deficiency always tested for, and aggravating factors eliminated when possible. Medical treatment is considered for severe or very severe forms and based on dopaminergic agonists, α2δ-1 ligands and/or opioids. First line treatment will be a low-dose monotherapy and the choice of treatment depends on the results of the clinical examination and investigations.
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Winkelmann J, Allen RP, Högl B, Inoue Y, Oertel W, Salminen AV, Winkelman JW, Trenkwalder C, Sampaio C. Treatment of restless legs syndrome: Evidence-based review and implications for clinical practice (Revised 2017)§. Mov Disord 2018; 33:1077-1091. [DOI: 10.1002/mds.27260] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 10/25/2017] [Accepted: 10/27/2017] [Indexed: 12/30/2022] Open
Affiliation(s)
- Juliane Winkelmann
- Institute of Neurogenomics; Helmholtz Zentrum München; Munich Germany
- Department of Neurology and Department of Human Genetics; Klinikum rechts der Isar, Technical University; Munich Germany
- Munich Cluster for Systems Neurology (SyNergy); Munich Germany
| | - Richard P. Allen
- Sleep Disorders Center; Johns Hopkins Bayview Medical Center; Baltimore Maryland USA
- Department of Neurology; Johns Hopkins University; Baltimore Maryland USA
| | - Birgit Högl
- Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - Yuichi Inoue
- Japan Somnology Center; Neuropsychiatric Research Institute; Tokyo Japan
- Department of Somnology; Tokyo Medical University; Tokyo Japan
| | - Wolfgang Oertel
- Department of Neurology; Philipps-Universität Marburg; Marburg Germany
| | - Aaro V. Salminen
- Institute of Neurogenomics; Helmholtz Zentrum München; Munich Germany
- Department of Neurology; Philipps-Universität Marburg; Marburg Germany
| | - John W. Winkelman
- Harvard Medical School; Boston Massachusetts USA
- Departments of Psychiatry and Neurology; Massachusetts General Hospital; Boston Massachusetts USA
| | - Claudia Trenkwalder
- Department of Neurosurgery; University Medical Center; Goettingen Germany
- Paracelsus-Elena Hospital; Kassel Germany
| | - Cristina Sampaio
- CHDI Foundation, Princeton, Princeton, NJ, USA, and the Instituto de Medicina Molecular; University of Lisbon; Lisbon Portugal
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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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19
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Abstract
Restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are under-recognized sleep disorders in children and adolescents. Several recent epidemiological studies have shown that RLS and PLMD are common in the pediatric population, and if left untreated, may lead to cardiovascular and neurocognitive consequences. Therefore, early diagnosis and intervention may help preventing long-term consequences. The management of RLS and PLMD in children involves both non-pharmacologic and pharmacologic approaches. Although there is emerging literature supporting medical therapy in children with RLS and PLMD, the overall experiences with these medications remain limited. Most children and adolescents with RLS and PLMD have low iron storage; therefore, iron therapy should be considered as the first line of treatment in children. Currently, there is no FDA-approved medication for RLS and PLMD in children. There is increasing evidence on the effectiveness of dopaminergic medications in children but the data are quite limited. Other medications such as α2δ-1 ligands, benzodiazepine, and clonidine are frequently used, but have not been adequately investigated in children. Further studies are needed to evaluate the safety and efficacy of pharmacologic therapy for RLS and PLMD in children.
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20
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Anderson JC, Fritz ML, Benson JM, Tracy BL. Nerve Decompression and Restless Legs Syndrome: A Retrospective Analysis. Front Neurol 2017; 8:287. [PMID: 28729849 PMCID: PMC5498562 DOI: 10.3389/fneur.2017.00287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 06/02/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction Restless legs syndrome (RLS) is a prevalent sleep disorder affecting quality of life and is often comorbid with other neurological diseases, including peripheral neuropathy. The mechanisms related to RLS symptoms remain unclear, and treatment options are often aimed at symptom relief rather than etiology. RLS may present in distinct phenotypes often described as “primary” vs. “secondary” RLS. Secondary RLS is often associated with peripheral neuropathy. Nerve decompression surgery of the common and superficial fibular nerves is used to treat peripheral neuropathy. Anecdotally, surgeons sometimes report improved RLS symptoms following nerve decompression for peripheral neuropathy. The purpose of this retrospective analysis was to quantify the change in symptoms commonly associated with RLS using visual analog scales (VAS). Methods Forty-two patients completed VAS scales (0–10) for pain, burning, numbness, tingling, weakness, balance, tightness, aching, pulling, cramping, twitchy/jumpy, uneasy, creepy/crawly, and throbbing, both before and 15 weeks after surgical decompression. Results Subjects reported significant improvement among all VAS categories, except for “pulling” (P = 0.14). The change in VAS following surgery was negatively correlated with the pre-surgery VAS for both the summed VAS (r = −0.58, P < 0.001) and the individual VAS scores (all P < 0.01), such that patients who reported the worst symptoms before surgery exhibited relatively greater reductions in symptoms after surgery. Conclusion This is the first study to suggest improvement in RLS symptoms following surgical decompression of the common and superficial fibular nerves. Further investigation is needed to quantify improvement using RLS-specific metrics and sleep quality assessments.
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Affiliation(s)
- James C Anderson
- Anderson Podiatry Center for Nerve Pain, Fort Collins, CO, United States
| | - Megan L Fritz
- Anderson Podiatry Center for Nerve Pain, Fort Collins, CO, United States.,Neuromuscular Function Lab, Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, United States
| | | | - Brian L Tracy
- Neuromuscular Function Lab, Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, United States
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21
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Veauthier C, Hasselmann H, Gold SM, Paul F. The Berlin Treatment Algorithm: recommendations for tailored innovative therapeutic strategies for multiple sclerosis-related fatigue. EPMA J 2016; 7:25. [PMID: 27904656 PMCID: PMC5121967 DOI: 10.1186/s13167-016-0073-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 10/21/2016] [Indexed: 12/11/2022]
Abstract
More than 80% of multiple sclerosis (MS) patients suffer from fatigue. Despite this, there are few therapeutic options and evidence-based pharmacological treatments are lacking. The associated societal burden is substantial (MS fatigue is a major reason for part-time employment or early retirement), and at least one out of four MS patients view fatigue as the most burdensome symptom of their disease. The mechanisms underlying MS-related fatigue are poorly understood, and objective criteria for distinguishing and evaluating levels of fatigue and tiredness have not yet been developed. A further complication is that both symptoms may also be unspecific indicators of many other diseases (including depression, sleep disorders, anemia, renal failure, liver diseases, chronic obstructive pulmonary disease, drug side effects, recent MS relapses, infections, nocturia, cancer, thyroid hypofunction, lack of physical exercise). This paper reviews current treatment options of MS-related fatigue in order to establish an individualized therapeutic strategy that factors in existing comorbid disorders. To ensure that such a strategy can also be easily and widely implemented, a comprehensive approach is needed, which ideally takes into account all other possible causes and which is moreover cost efficient. Using a diagnostic interview, depressive disorders, sleep disorders and side effects of the medication should be identified and addressed. All MS patients suffering from fatigue should fill out the Modified Fatigue Impact Scale, Epworth Sleepiness Scale, the Beck Depression Inventory (or a similar depression scale), and the Pittsburgh Sleep Quality Index (or the Insomnia Severity Index). In some patients, polygraphic or polysomnographic investigations should be performed. The treatment of underlying sleep disorders, drug therapy with alfacalcidol or fampridine, exercise therapy, and cognitive behavioral therapy-based interventions may be effective against MS-related fatigue. The objectives of this article are to identify the reasons for fatigue in patients suffering from multiple sclerosis and to introduce individually tailored treatment approaches. Moreover, this paper focuses on current knowledge about MS-related fatigue in relation to brain atrophy and lesions, cognition, disease course, and other findings in an attempt to identify future research directions.
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Affiliation(s)
- Christian Veauthier
- Interdisciplinary Center for Sleep Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ; NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Helge Hasselmann
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ; Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Stefan M Gold
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203 Berlin, Germany ; Institute of Neuroimmunology and Multiple Sclerosis (INIMS), Center for Molecular Neurobiology (ZMNH), University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany ; Clinical and Experimental Multiple Sclerosis Research Center, Department of Neurology, Charité - Universitätsmedizin Berlin, 10117 Berlin, Germany ; Experimental and Clinical Research Center, Max Delbrück Center for Molecular Medicine and Charité - Universitätsmedizin Berlin, Berlin, Germany
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22
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Winkelman JW, Armstrong MJ, Allen RP, Chaudhuri KR, Ondo W, Trenkwalder C, Zee PC, Gronseth GS, Gloss D, Zesiewicz T. Practice guideline summary: Treatment of restless legs syndrome in adults: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2016; 87:2585-2593. [PMID: 27856776 DOI: 10.1212/wnl.0000000000003388] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 08/02/2016] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To make evidence-based recommendations regarding restless legs syndrome (RLS) management in adults. METHODS Articles were classified per the 2004 American Academy of Neurology evidence rating scheme. Recommendations were tied to evidence strength. RESULTS AND RECOMMENDATIONS In moderate to severe primary RLS, clinicians should consider prescribing medication to reduce RLS symptoms. Strong evidence supports pramipexole, rotigotine, cabergoline, and gabapentin enacarbil use (Level A); moderate evidence supports ropinirole, pregabalin, and IV ferric carboxymaltose use (Level B). Clinicians may consider prescribing levodopa (Level C). Few head-to-head comparisons exist to suggest agents preferentially. Cabergoline is rarely used (cardiac valvulopathy risks). Augmentation risks with dopaminergic agents should be considered. When treating periodic limb movements of sleep, clinicians should consider prescribing ropinirole (Level A) or pramipexole, rotigotine, cabergoline, or pregabalin (Level B). For subjective sleep measures, clinicians should consider prescribing cabergoline or gabapentin enacarbil (Level A), or ropinirole, pramipexole, rotigotine, or pregabalin (Level B). For patients failing other treatments for RLS symptoms, clinicians may consider prescribing prolonged-release oxycodone/naloxone where available (Level C). In patients with RLS with ferritin ≤75 μg/L, clinicians should consider prescribing ferrous sulfate with vitamin C (Level B). When nonpharmacologic approaches are desired, clinicians should consider prescribing pneumatic compression (Level B) and may consider prescribing near-infrared spectroscopy or transcranial magnetic stimulation (Level C). Clinicians may consider prescribing vibrating pads to improve subjective sleep (Level C). In patients on hemodialysis with secondary RLS, clinicians should consider prescribing vitamin C and E supplementation (Level B) and may consider prescribing ropinirole, levodopa, or exercise (Level C).
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Affiliation(s)
- John W Winkelman
- From Harvard Medical School and Massachusetts General Hospital (J.W.W.), Boston; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology (R.P.A.), Johns Hopkins University, Baltimore, MD; King's College and King's College Hospital (K.R.C.), London; Methodist Neurological Institute (W.O.), Houston, TX; Department of Neurology (C.T.), University Medical Center, Göttingen, Germany; Northwestern University Feinberg School of Medicine (P.C.Z.), Chicago, IL; University of Kansas Medical Center (G.S.G.), Kansas City; CAMC Neurology Section (D.G.), Charleston, WV; and Department of Neurology (T.Z.), University of South Florida, James A Haley Veterans Administration Hospital, Tampa
| | - Melissa J Armstrong
- From Harvard Medical School and Massachusetts General Hospital (J.W.W.), Boston; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology (R.P.A.), Johns Hopkins University, Baltimore, MD; King's College and King's College Hospital (K.R.C.), London; Methodist Neurological Institute (W.O.), Houston, TX; Department of Neurology (C.T.), University Medical Center, Göttingen, Germany; Northwestern University Feinberg School of Medicine (P.C.Z.), Chicago, IL; University of Kansas Medical Center (G.S.G.), Kansas City; CAMC Neurology Section (D.G.), Charleston, WV; and Department of Neurology (T.Z.), University of South Florida, James A Haley Veterans Administration Hospital, Tampa
| | - Richard P Allen
- From Harvard Medical School and Massachusetts General Hospital (J.W.W.), Boston; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology (R.P.A.), Johns Hopkins University, Baltimore, MD; King's College and King's College Hospital (K.R.C.), London; Methodist Neurological Institute (W.O.), Houston, TX; Department of Neurology (C.T.), University Medical Center, Göttingen, Germany; Northwestern University Feinberg School of Medicine (P.C.Z.), Chicago, IL; University of Kansas Medical Center (G.S.G.), Kansas City; CAMC Neurology Section (D.G.), Charleston, WV; and Department of Neurology (T.Z.), University of South Florida, James A Haley Veterans Administration Hospital, Tampa
| | - K Ray Chaudhuri
- From Harvard Medical School and Massachusetts General Hospital (J.W.W.), Boston; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology (R.P.A.), Johns Hopkins University, Baltimore, MD; King's College and King's College Hospital (K.R.C.), London; Methodist Neurological Institute (W.O.), Houston, TX; Department of Neurology (C.T.), University Medical Center, Göttingen, Germany; Northwestern University Feinberg School of Medicine (P.C.Z.), Chicago, IL; University of Kansas Medical Center (G.S.G.), Kansas City; CAMC Neurology Section (D.G.), Charleston, WV; and Department of Neurology (T.Z.), University of South Florida, James A Haley Veterans Administration Hospital, Tampa
| | - William Ondo
- From Harvard Medical School and Massachusetts General Hospital (J.W.W.), Boston; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology (R.P.A.), Johns Hopkins University, Baltimore, MD; King's College and King's College Hospital (K.R.C.), London; Methodist Neurological Institute (W.O.), Houston, TX; Department of Neurology (C.T.), University Medical Center, Göttingen, Germany; Northwestern University Feinberg School of Medicine (P.C.Z.), Chicago, IL; University of Kansas Medical Center (G.S.G.), Kansas City; CAMC Neurology Section (D.G.), Charleston, WV; and Department of Neurology (T.Z.), University of South Florida, James A Haley Veterans Administration Hospital, Tampa
| | - Claudia Trenkwalder
- From Harvard Medical School and Massachusetts General Hospital (J.W.W.), Boston; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology (R.P.A.), Johns Hopkins University, Baltimore, MD; King's College and King's College Hospital (K.R.C.), London; Methodist Neurological Institute (W.O.), Houston, TX; Department of Neurology (C.T.), University Medical Center, Göttingen, Germany; Northwestern University Feinberg School of Medicine (P.C.Z.), Chicago, IL; University of Kansas Medical Center (G.S.G.), Kansas City; CAMC Neurology Section (D.G.), Charleston, WV; and Department of Neurology (T.Z.), University of South Florida, James A Haley Veterans Administration Hospital, Tampa
| | - Phyllis C Zee
- From Harvard Medical School and Massachusetts General Hospital (J.W.W.), Boston; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology (R.P.A.), Johns Hopkins University, Baltimore, MD; King's College and King's College Hospital (K.R.C.), London; Methodist Neurological Institute (W.O.), Houston, TX; Department of Neurology (C.T.), University Medical Center, Göttingen, Germany; Northwestern University Feinberg School of Medicine (P.C.Z.), Chicago, IL; University of Kansas Medical Center (G.S.G.), Kansas City; CAMC Neurology Section (D.G.), Charleston, WV; and Department of Neurology (T.Z.), University of South Florida, James A Haley Veterans Administration Hospital, Tampa
| | - Gary S Gronseth
- From Harvard Medical School and Massachusetts General Hospital (J.W.W.), Boston; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology (R.P.A.), Johns Hopkins University, Baltimore, MD; King's College and King's College Hospital (K.R.C.), London; Methodist Neurological Institute (W.O.), Houston, TX; Department of Neurology (C.T.), University Medical Center, Göttingen, Germany; Northwestern University Feinberg School of Medicine (P.C.Z.), Chicago, IL; University of Kansas Medical Center (G.S.G.), Kansas City; CAMC Neurology Section (D.G.), Charleston, WV; and Department of Neurology (T.Z.), University of South Florida, James A Haley Veterans Administration Hospital, Tampa
| | - David Gloss
- From Harvard Medical School and Massachusetts General Hospital (J.W.W.), Boston; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology (R.P.A.), Johns Hopkins University, Baltimore, MD; King's College and King's College Hospital (K.R.C.), London; Methodist Neurological Institute (W.O.), Houston, TX; Department of Neurology (C.T.), University Medical Center, Göttingen, Germany; Northwestern University Feinberg School of Medicine (P.C.Z.), Chicago, IL; University of Kansas Medical Center (G.S.G.), Kansas City; CAMC Neurology Section (D.G.), Charleston, WV; and Department of Neurology (T.Z.), University of South Florida, James A Haley Veterans Administration Hospital, Tampa
| | - Theresa Zesiewicz
- From Harvard Medical School and Massachusetts General Hospital (J.W.W.), Boston; Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville; Department of Neurology (R.P.A.), Johns Hopkins University, Baltimore, MD; King's College and King's College Hospital (K.R.C.), London; Methodist Neurological Institute (W.O.), Houston, TX; Department of Neurology (C.T.), University Medical Center, Göttingen, Germany; Northwestern University Feinberg School of Medicine (P.C.Z.), Chicago, IL; University of Kansas Medical Center (G.S.G.), Kansas City; CAMC Neurology Section (D.G.), Charleston, WV; and Department of Neurology (T.Z.), University of South Florida, James A Haley Veterans Administration Hospital, Tampa
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23
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Abstract
Symptoms of restless legs syndrome (RLS) are common in patients with chronic kidney disease (CKD) on dialysis; symptoms of RLS are estimated to affect up to 25% of patients on dialysis when the international RLS diagnostic criteria are applied. RLS is a neurologic disorder with a circadian rhythmicity characterized by an overwhelming urge to move the legs during rest, which can be relieved temporarily by movement. RLS has been associated with an increase in sleep disturbance, higher cardiovascular morbidity, decreased quality of life, and an increased risk of death in patients with CKD. Although the exact pathophysiology of RLS is unknown, it is thought to involve an imbalance in iron metabolism and dopamine neurotransmission in the brain. The symptoms of moderate to severe RLS can be treated with several pharmacologic agents; however, data specific to patients on dialysis with RLS are lacking. The purpose of this article is to examine the relationship between, and complications of, RLS and CKD both in dialysis and nondialysis patients, and discuss the treatment options for patients on dialysis with RLS.
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Affiliation(s)
- Marta Novak
- University Health Network, Department of Psychiatry, University of Toronto, Toronto, Canada; Institute of Behavioral Sciences, Semmelweis University, Budapest, Hungary.
| | - John W Winkelman
- Department of Psychiatry, Sleep Disorders Clinical Research Program, Massachusetts General Hospital, Boston, MA
| | - Mark Unruh
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM
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24
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Abstract
OBJECTIVE To evaluate the efficacy and safety of pregabalin for the treatment of restless legs syndrome (RLS). DATA SOURCES A search of the MEDLINE database (1956-February 2016) and EMBASE (1957-February 2016) was conducted, using the terms pregabalin and restless legs syndrome In addition, a manual review of the references cited in each publication identified from the database search was conducted to identify relevant articles. STUDY SELECTION AND DATA EXTRACTION All English-language, peer-reviewed publications were evaluated for relevance. From an initial review of 285 articles, 5 clinical trials were included in the final analysis. DATA SYNTHESIS Pregabalin is an analog of γ-aminobutyric acid that exhibits antinociceptive and anticonvulsant activity by binding to voltage-gated calcium channels in the central nervous system. Studies of pregabalin have demonstrated efficacy through significant reductions in mean International RLS Scale scores and wake after sleep onset scores, and it had a lower rate of augmentation than pramipexole treatment. Study durations ranged from 6 to 52 weeks, with doses ranging from 150 to 600 mg daily. The most common adverse effects associated with pregabalin use in all studies included dizziness and somnolence. CONCLUSIONS Clinical evidence suggests that pregabalin may improve symptoms of RLS and reduce disturbances in sleep, resulting in improvements in quality of life for patients affected by the disease. Pregabalin is considered to be relatively safe and poses a minimal risk of augmentation unlike current recommended first-line treatments for RLS. Thus, evidence suggests that pregabalin is a reasonable therapeutic option for the treatment of RLS.
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25
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Schjerning O, Rosenzweig M, Pottegård A, Damkier P, Nielsen J. Abuse Potential of Pregabalin: A Systematic Review. CNS Drugs 2016; 30:9-25. [PMID: 26767525 DOI: 10.1007/s40263-015-0303-6] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Several case reports and epidemiological studies have raised concern about the abuse potential of pregabalin, the use of which has increased substantially over the last decade. Pregabalin is, in some cases, used for recreational purposes and it has incurred attention among drug abusers for causing euphoric and dissociative effects when taken in doses exceeding normal therapeutic dosages or used by alternative routes of administration, such as nasal insufflation or venous injection. The magnitude of the abuse potential and the mechanism behind it are not fully known. OBJECTIVE The aim of this study was to present a systematic review of the data concerning the abuse potential of pregabalin. METHODS We performed a systematic literature search and reviewed the preclinical, clinical and epidemiological data on the abuse potential of pregabalin. RESULTS We included preclinical (n = 17), clinical (n = 19) and epidemiological (n = 13) studies addressing the abuse potential of pregabalin. We also reviewed case reports (n = 9) concerning abuse of pregabalin. The preclinical studies indicated that pregabalin possesses modulatory effects on the GABA and glutamate systems, leaving room for an abuse potential. Further, clinical studies reported euphoria as a frequent side effect in patients treated with pregabalin. The majority of case reports concerning abuse of pregabalin involved patients with a history of substance abuse and, similarly, epidemiological studies found evidence of abuse, especially among opiate abusers. CONCLUSIONS Overall, the available literature suggests an important clinical abuse potential of pregabalin and prescribers should pay attention to signs of abuse, especially in patients with a history of substance abuse.
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Affiliation(s)
- Ole Schjerning
- Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark. .,Centre for Schizophrenia, Brandevej 5, 9220, Aalborg, Denmark.
| | | | - Anton Pottegård
- Clinical Pharmacology, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Per Damkier
- Clinical Pharmacology, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Department of Clinical Chemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Jimmi Nielsen
- Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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26
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Trenkwalder C, Winkelmann J, Inoue Y, Paulus W. Restless legs syndrome-current therapies and management of augmentation. Nat Rev Neurol 2015. [PMID: 26215616 DOI: 10.1038/nrneurol.2015.122] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Idiopathic restless legs syndrome (RLS) can severely affect quality of life and disturb sleep, so that pharmacological treatment is necessary, especially for elderly patients. Treatment guidelines recommend initiation of therapy with dopamine agonists (pramipexole, ropinirole or the rotigotine transdermal patch, all approved in most countries) or α-2-δ ligands (gabapentin enacarbil, approved in the USA and Japan), depending on the country and availability. Where approved, opioids (prolonged release oxycodone-naloxone, approved in Europe) are also recommended as a second-line therapy for severe RLS. Several iron formulations can be effective but are not yet approved for RLS therapy, whereas benzodiazepines and other anticonvulsants are not recommended or approved. Less is known about effective management of RLS that is associated with other conditions, such as uraemia or pregnancy. Furthermore, very little data are available on the management of RLS when first-line treatment fails or patients experience augmentation. In this Review, we summarize state-of-the-art therapies for RLS in the context of the diagnostic criteria and available guidelines, based on knowledge ranging from Class I evidence for the treatment of idiopathic RLS to Class IV evidence for the treatment of complications such as augmentation. We consider therapies, including combination therapies, that are used in clinical practice for long-term management of RLS, despite a lack of trials and approval, and highlight the need for practical long-term evaluation of current trials.
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Affiliation(s)
- Claudia Trenkwalder
- 1] Paracelsus Elena Klinik, Centre of Parkinsonism and Movement Disorders, Kassel, Klinikstrasse 16, 34128 Kassel, Germany. [2] Department of Neurosurgery, University Medical Centre Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
| | - Juliane Winkelmann
- 1] Department of Neurology and Neurological Sciences and Centre for Sleep Sciences and Medicine, Stanford University, 3165 Porter Drive Palo Alto, CA 94304, USA. [2] Neurologische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, 81675 Munich, Germany
| | - Yuichi Inoue
- 1] Japan Somnology Center, Neuropsychiatric Research Institute, 1-17-7-301 Yoyogi, Shibuya-ku, Tokyo 151-0053, Japan. [2] Department of Somnology, Tokyo Medical University, Nishi-Shinjuku 6-7-1, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Walter Paulus
- Department of Clinical Neurophysiology, University Medical Centre Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany
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28
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Abstract
"What will you give my child to help him sleep?" is a common question parents ask and some health care providers abhor hearing. Entire families may suffer when one member does not sleep well. Poor sleep may complicate the management of other comorbid conditions. Health care providers may have received only limited education on sleep disorders and are frequently forced to choose between treatment options that are poorly studied in children. Fortunately, when addressed correctly, many children with chronic sleep disorders may improve their sleep and daytime behavior in a relatively short time. This review provides a framework to help understand the causes of poor sleep in children and the potential pharmacologic options.
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Affiliation(s)
- Matthew M Troester
- Department of Neurology, University of Arizona College of Medicine, Phoenix, AZ; Department of Pediatrics, Creighton University College of Medicine, Omaha, NE; Comprehensive Sleep Medicine Program, Phoenix Children's Hospital, Phoenix, AZ.
| | - Rafael Pelayo
- Stanford Sleep Disorders Clinic, Stanford University School of Medicine, Redwood City, CA
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29
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Wijemanne S, Jankovic J. Restless legs syndrome: clinical presentation diagnosis and treatment. Sleep Med 2015; 16:678-90. [PMID: 25979181 DOI: 10.1016/j.sleep.2015.03.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 02/28/2015] [Accepted: 03/02/2015] [Indexed: 12/27/2022]
Abstract
Restless legs syndrome (RLS) is a circadian disorder of sensory-motor integration that may be related to genetically determined dysregulation of iron transport across the blood-brain barrier. Dopamine agonists (DAs) have been considered the first-line therapy, but with the growing appreciation of problems associated with long-term treatment, particularly augmentation and impulse control disorder, alpha-2-delta drugs, such as gabapentin, are now considered the first line of treatment in patients with troublesome RLS. Opioids can be considered as an alternative therapy, particularly in patients with DA-related augmentation. In more severe cases, a combination therapy may be required. Intravenous iron therapy may be considered on those patients with refractory RLS.
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Affiliation(s)
- Subhashie Wijemanne
- Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA.
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30
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Fröhlich AC, Eckeli AL, Bacelar A, Poyares D, Pachito DV, Stelzer FG, Coelho FMS, Rizzo GNV, Prado GFD, Sander HH, Goulart LI, Lucchesi LM, Gitai LLG, Prado LBFD, Ataíde-Junior L, Bezerra MLDS, Lopes MC, Trentin MM, Rodrigues RND, Hasan R, Alves RSC, Schönwald SV, Moraes WADS. Brazilian consensus on guidelines for diagnosis and treatment for restless legs syndrome. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:260-280. [PMID: 25807136 DOI: 10.1590/0004-282x20140239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 12/04/2014] [Indexed: 06/04/2023]
Abstract
The Consensus on restless legs syndrome is an effort of neurologists from several Brazilian states, which tirelessly reviewed the literature of recent years in search of evidence, both in regard to diagnosis and treatment, according to the Oxford Centre for Evidence-based Medicine.
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Affiliation(s)
| | - Alan Luiz Eckeli
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto, SP, Brazil
| | | | - Dalva Poyares
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | | | | | | | | | | | - Heidi Haueisen Sander
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto, SP, Brazil
| | | | | | | | | | | | | | - Maria Cecília Lopes
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
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An update on restless legs syndrome (Willis-Ekbom disease): clinical features, pathogenesis and treatment. Curr Opin Neurol 2015; 27:493-501. [PMID: 24978636 DOI: 10.1097/wco.0000000000000117] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW In recent years, there have been a number of advances in the field of restless legs syndrome (RLS) or Willis-Ekbom disease (WED). Here, we review recent studies pertaining to the diagnosis and clinical features, pathogenesis, and treatment of RLS/WED. RECENT FINDINGS Recent studies have added a temporal dimension to RLS/WED epidemiology by examining both the incidence and persistence rates in different populations. Diagnostic criteria have been modified to increase sensitivity, and new guidelines take into account recently published studies of different drug classes. SUMMARY Recent epidemiological findings have shown that RLS/WED is a common neurological disorder that affects up to 5% of the adult population in Western countries. In moderate and severe cases, RLS/WED has a strong impact on sleep and quality of life and can involve an increased cardiovascular risk. Diagnosis is made clinically by confirming the presence of the five essential criteria. However, in difficult cases objective tests such as the multiple suggested immobilization test (m-SIT) can be used. The pathophysiology is partially known, with several risk polymorphisms (BTBD-9 (BTB (POZ) domain containing 9), MEIS-1 (Meis homeobox 1), protein tyrosine phosphatase, receptor type, D, and others) playing an important role, along with dopaminergic and iron dysfunctions. The disorder frequently requires long-term treatment with low-dose dopamine agonists or α2δ ligands. Dopamine agonists are usually effective but the main complication, RLS/WED augmentation, can arise.
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Rist PM, Tzourio C, Elbaz A, Soumaré A, Dufouil C, Mazoyer B, Kurth T. Structural brain lesions and restless legs syndrome: a cross-sectional population-based study. BMJ Open 2014; 4:e005938. [PMID: 25421338 PMCID: PMC4244423 DOI: 10.1136/bmjopen-2014-005938] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To evaluate the association between white matter lesion (WML) volume, silent infarcts and restless legs syndrome (RLS) in a population-based study of elderly individuals. DESIGN Cross-sectional study. SETTING Population-based Three-City study. PARTICIPANTS 1035 individuals from the Dijon, France, centre of the Three-City study who had available information on volume of WMLs from MRIs and who answered questions about the prevalence of RLS. PRIMARY OUTCOME MEASURE Prevalence of RLS. RESULTS WML volume was measured using an automated tissue segmentation method. Logistic regression was used to evaluate adjusted associations between tertiles of WML volume and RLS and between silent infarcts and RLS. 218 individuals (21.1%) were determined to have RLS. Compared with those in the first tertile of WML volume, individuals in the second tertile (OR=1.09; 95% CI 0.75 to 1.60) or third tertile (OR=1.17; 95% CI 0.79 to 1.74) did not have an increased prevalence of RLS. We also did not observe associations between the volume of deep or periventricular WML and RLS; nor did we observe an association between silent brain infarcts and RLS (OR=0.74; 95% CI 0.40 to 1.39). These findings were not modified by age or gender. CONCLUSIONS Higher volume of WML and the presence of silent infarcts were not associated with an increased prevalence of RLS in this population-based cohort of elderly individuals.
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Affiliation(s)
- Pamela M Rist
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology,Harvard School of Public Health, Boston, Massachusetts, USA
| | - Christophe Tzourio
- INSERM Research Center for Epidemiology and Biostatistics (U897) Team Neuroepidemiology, Bordeaux, France
- College of Health Sciences, University of Bordeaux, Bordeaux, France
| | - Alexis Elbaz
- Social and Occupational Determinants of Health, INSERM, Centre for Research in Epidemiology and Population Health, U1018, Villejuif, France
- Université de Versailles St-Quentin, Versailles, France
| | - Aïcha Soumaré
- INSERM Research Center for Epidemiology and Biostatistics (U897) Team Neuroepidemiology, Bordeaux, France
| | - Carole Dufouil
- INSERM Research Center for Epidemiology and Biostatistics (U897) Team Neuroepidemiology, Bordeaux, France
- College of Health Sciences, University of Bordeaux, Bordeaux, France
| | - Bernard Mazoyer
- College of Health Sciences, University of Bordeaux, Bordeaux, France
- CNRS CEA (UMR5296) Neurofunctional Imaging Group, University of Bordeaux, Bordeaux, France
| | - Tobias Kurth
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology,Harvard School of Public Health, Boston, Massachusetts, USA
- INSERM Research Center for Epidemiology and Biostatistics (U897) Team Neuroepidemiology, Bordeaux, France
- College of Health Sciences, University of Bordeaux, Bordeaux, France
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de Biase S, Merlino G, Lorenzut S, Valente M, Gigli GL. ADMET considerations when prescribing novel therapeutics to treat restless legs syndrome. Expert Opin Drug Metab Toxicol 2014; 10:1365-80. [DOI: 10.1517/17425255.2014.952629] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Roth T, Arnold LM, Garcia-Borreguero D, Resnick M, Clair AG. A review of the effects of pregabalin on sleep disturbance across multiple clinical conditions. Sleep Med Rev 2014; 18:261-71. [DOI: 10.1016/j.smrv.2013.07.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 07/12/2013] [Accepted: 07/30/2013] [Indexed: 11/30/2022]
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Ferini-Strambi L, Marelli S. Pharmacotherapy for restless legs syndrome. Expert Opin Pharmacother 2014; 15:1127-38. [DOI: 10.1517/14656566.2014.908850] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Garcia-Borreguero D, Patrick J, DuBrava S, Becker PM, Lankford A, Chen C, Miceli J, Knapp L, Allen RP. Pregabalin versus pramipexole: effects on sleep disturbance in restless legs syndrome. Sleep 2014; 37:635-43. [PMID: 24899755 PMCID: PMC4044751 DOI: 10.5665/sleep.3558] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES To compare pregabalin versus placebo and pramipexole for reducing restless legs syndrome (RLS)-related sleep disturbance. DESIGN Randomized, double-blinded, crossover trial. SETTING Twenty-three US sleep centers. PARTICIPANTS Eighty-five individuals with moderate to severe idiopathic RLS and associated sleep disturbance. INTERVENTIONS Participants were randomized across 6 treatment sequences comprising three 4-week periods on pregabalin 300 mg/day (n = 75), pramipexole 0.5 mg/day (n = 76), or placebo (n = 73). MEASUREMENTS AND RESULTS Polysomnography was conducted over 2 nights at the end of each period. Primary (wake after sleep onset [WASO], pregabalin vs placebo) and key secondary endpoints were analyzed for statistical significance, with descriptive statistics for other endpoints. Pregabalin improved sleep maintenance, demonstrated by reductions in WASO (-27.1 min vs placebo [P < 0.0001]; -26.9 vs pramipexole) and number of awakenings after sleep onset (-2.7 vs placebo; -7.9 vs pramipexole [P < 0.0001]) by polysomnography, and an increase in subjective total sleep time (30.8 min vs placebo [P < 0.0001]; 26.8 vs pramipexole). Pregabalin also increased slow wave sleep duration (20.9 min vs placebo; 32.1 vs pramipexole [P < 0.0001]). Reduction in periodic limb movement arousal index (PLMAI) with pregabalin was similar to pramipexole and greater than placebo (-3.7 PLMA/h [P < 0.0001]), although reduction in total PLM in sleep was less than for pramipexole. CONCLUSIONS This study demonstrated improvements in objective and subjective measures of sleep maintenance and sleep architecture with pregabalin compared with placebo and pramipexole. Effects of pregabalin on periodic limb movement arousal index were comparable to pramipexole. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT00991276; http://clinicaltrials.gov/show/NCT00991276.
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Affiliation(s)
| | | | | | | | | | - Crystal Chen
- Pfizer Global Research and Development, Groton, CT
| | | | - Lloyd Knapp
- Pfizer Global Research and Development, Groton, CT
| | - Richard P. Allen
- Johns Hopkins University, Department of Neurology, Baltimore, MD
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Yang JS, Cho YJ, Kang SH, Choi HJ. Demographic and clinical characteristics of patients with restless legs syndrome in spine clinic. J Korean Neurosurg Soc 2014; 55:83-8. [PMID: 24653801 PMCID: PMC3958578 DOI: 10.3340/jkns.2014.55.2.83] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/19/2013] [Accepted: 01/10/2014] [Indexed: 01/18/2023] Open
Abstract
Objective The restless legs syndrome (RLS) is a common disorder affecting up to 5% to 15% of the general population, in which the incidence increases with age, and includes paresthesia in the legs. The purpose of this study is to investigate the incidence of RLS in spine center and to review clinical manifestations of this syndrome and its current treatments. Methods Over a period of a year, retrospective medical record review and lumbar magnetic resonance images were performed on 32 patients with RLS in spine clinic who were diagnosed by National Institutes of Health criteria. Affected limbs were classified as five. Two grading systems were used in the evaluation of neural compromises. Results The incidence of RLS was 5.00% (32/639). There were 16 males (50%) and 16 females (50%). The median age at diagnosis was 55.4 years (range, 25-93 years). There are no correlation between the affected limbs of RLS and neural compromises on the lumbar spine. Conclusion The RLS is a clearly common neurologic disorder of the limbs, usually the legs. The awareness of this syndrome can help reduce diagnostic error; thereby, avoiding the morbidity and expense associated with unnecessary studies or inappropriate treatments in RLS patients.
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Affiliation(s)
- Jin Seo Yang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Yong Jun Cho
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Suk Hyung Kang
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
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Allen RP, Chen C, Garcia-Borreguero D, Polo O, DuBrava S, Miceli J, Knapp L, Winkelman JW. Comparison of pregabalin with pramipexole for restless legs syndrome. N Engl J Med 2014; 370:621-31. [PMID: 24521108 DOI: 10.1056/nejmoa1303646] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Dopaminergic medications relieve symptoms of the restless legs syndrome (RLS) but have the potential to cause iatrogenic worsening (augmentation) of RLS with long-term treatment. Pregabalin may be an effective alternative. METHODS In this 52-week, randomized, double-blind trial, we assessed efficacy and augmentation in patients with RLS who were treated with pregabalin as compared with placebo and pramipexole. Patients were randomly assigned to receive 52 weeks of treatment with pregabalin at a dose of 300 mg per day or pramipexole at a dose of 0.25 mg or 0.5 mg per day or 12 weeks of placebo followed by 40 weeks of randomly assigned active treatment. The primary analyses involved a comparison of pregabalin and placebo over a period of 12 weeks with use of the International RLS (IRLS) Study Group Rating Scale (on which the score ranges from 0 to 40, with a higher score indicating more severe symptoms), the Clinical Global Impression of Improvement scale (which was used to assess the proportion of patients with symptoms that were "very much improved" or "much improved"), and a comparison of rates of augmentation with pregabalin and pramipexole over a period of 40 or 52 weeks of treatment. RESULTS A total of 719 participants received daily treatment, 182 with 300 mg of pregabalin, 178 with 0.25 mg of pramipexole, 180 with 0.5 mg of pramipexole, and 179 with placebo. Over a period of 12 weeks, the improvement (reduction) in mean scores on the IRLS scale was greater, by 4.5 points, among participants receiving pregabalin than among those receiving placebo (P<0.001), and the proportion of patients with symptoms that were very much improved or much improved was also greater with pregabalin than with placebo (71.4% vs. 46.8%, P<0.001). The rate of augmentation over a period of 40 or 52 weeks was significantly lower with pregabalin than with pramipexole at a dose of 0.5 mg (2.1% vs. 7.7%, P=0.001) but not at a dose of 0.25 mg (2.1% vs. 5.3%, P=0.08). There were six cases of suicidal ideation in the group receiving pregabalin, three in the group receiving 0.25 mg of pramipexole, and two in the group receiving 0.5 mg of pramipexole. CONCLUSIONS Pregabalin provided significantly improved treatment outcomes as compared with placebo, and augmentation rates were significantly lower with pregabalin than with 0.5 mg of pramipexole. (Funded by Pfizer; ClinicalTrials.gov number, NCT00806026.).
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Affiliation(s)
- Richard P Allen
- From the Department of Neurology, Johns Hopkins University, Baltimore (R.P.A.); Pfizer Global Research and Development, Groton, CT (C.C., S.D., J.M., L.K.); Sleep Research Institute, Madrid (D.G.-B.); the Department of Pulmonary Medicine, Tampere University Hospital, Tampere, Finland (O.P.); and Massachusetts General Hospital, Boston (J.W.W.)
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[Practical guidelines for diagnosis and therapy of restless legs syndrome]. DER NERVENARZT 2014; 85:9-10, 12-4, 16-8. [PMID: 24414246 DOI: 10.1007/s00115-013-3888-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Restless legs syndrome (RLS) is the most common neurological sleep disorder affecting 10 % of the Caucasian population. The disorder is characterized by painful sensations in the lower limbs, especially during the evening, at night and during rest, resulting in an urge to move the legs and insomnia. As a result the quality of life is significantly reduced. Dopaminergic agents, opioids and anticonvulsants have proven to be effective for RLS with only the former being currently licensed; however, affected patients have to be identified, which is not always the case, especially in outpatient settings. Possible impediments to the adequate management of patients with RLS may include a lack of awareness, comorbidities and other medical conditions mimicking RLS. To overcome some of these difficulties practical guidelines for the diagnosis and therapy of RLS are provided.
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Jobert M, Wilson FJ, Roth T, Ruigt GSF, Anderer P, Drinkenburg WHIM, Bes FW, Brunovsky M, Danker-Hopfe H, Freeman J, van Gerven JMA, Gruber G, Kemp B, Klösch G, Ma J, Penzel T, Peterson BT, Schulz H, Staner L, Saletu B, Svetnik V. Guidelines for the recording and evaluation of pharmaco-sleep studies in man: the International Pharmaco-EEG Society (IPEG). Neuropsychobiology 2014; 67:127-67. [PMID: 23548759 DOI: 10.1159/000343449] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 11/26/2012] [Indexed: 01/19/2023]
Abstract
The International Pharmaco-EEG Society (IPEG) presents guidelines summarising the requirements for the recording and computerised evaluation of pharmaco-sleep data in man. Over the past years, technical and data-processing methods have advanced steadily, thus enhancing data quality and expanding the palette of sleep assessment tools that can be used to investigate the activity of drugs on the central nervous system (CNS), determine the time course of effects and pharmacodynamic properties of novel therapeutics, hence enabling the study of the pharmacokinetic/pharmacodynamic relationship, and evaluate the CNS penetration or toxicity of compounds. However, despite the presence of robust guidelines on the scoring of polysomnography -recordings, a review of the literature reveals inconsistent -aspects in the operating procedures from one study to another. While this fact does not invalidate results, the lack of standardisation constitutes a regrettable shortcoming, especially in the context of drug development programmes. The present guidelines are intended to assist investigators, who are using pharmaco-sleep measures in clinical research, in an effort to provide clear and concise recommendations and thereby to standardise methodology and facilitate comparability of data across laboratories.
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Affiliation(s)
- Marc Jobert
- International Pharmaco-EEG Society, Berlin, Germany.
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Abstract
Restless legs syndrome (RLS) is a common disorder diagnosed by the clinical characteristics of restlessness in the legs associated often with abnormal sensations that start at rest and are improved by activity, occurring with a diurnal pattern of worsened symptoms at night and improvement in the morning. RLS is the cause of impaired quality of life in those more severely afflicted. Treatment of RLS has undergone considerable change over the last few years. Several classes of medications have demonstrated efficacy, including the dopaminergic agents and the alpha-2-delta ligands. Levodopa was the first dopaminergic agent found to be successful. However, chronic use of levodopa is frequently associated with augmentation that is defined as an earlier occurrence of symptoms frequently associated with worsening severity and sometimes spread to other body areas. The direct dopamine agonists, including ropinirole, pramipexole, and rotigotine patch, are also effective, although side effects, including daytime sleepiness, impulse control disorders, and augmentation, may limit usefulness. The alpha-2-delta ligands, including gabapentin, gabapentin enacarbil, and pregabalin, are effective for RLS without known occurrence of augmentation or impulse control disorders, although sedation and dizziness can occur. Other agents, including the opioids and clonazepam do not have sufficient evidence to recommend them as treatment for RLS, although in an individual patient, they may provide benefit.
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Affiliation(s)
- Cynthia L Comella
- Movement Disorders Section, Department of Neurological Sciences, Rush Medical College, 1725 West Harrison Street, Suite 755, Chicago, IL, 60612, USA,
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Winkelman JW, Gagnon A, Clair AG. Sensory symptoms in restless legs syndrome: the enigma of pain. Sleep Med 2013; 14:934-42. [DOI: 10.1016/j.sleep.2013.05.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 04/12/2013] [Accepted: 05/18/2013] [Indexed: 01/18/2023]
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Abstract
Restless legs syndrome (RLS) is a common sensory motor neurological disorder that is characterised by an irresistible urge to move the legs that significantly affects the quality of life of the patient. Prevalence in the general population is 5-25% and it is twice as prevalent in women as in men. RLS is the most common movement disorder in pregnancy with a fourfold increased risk of developing this disorder later in life. The pathophysiology of RLS is centred on dopaminergic dysfunction, reduced central nervous system iron, genetic linkages, or alteration in neurotransmitters such as hypocretins, endorphins levels and immune dysfunction and inflammatory mechanisms. With the emergence of new evidence, there are changes to the previous treatment recommendations for RLS. There is sufficient evidence to conclude that dopamine agonists such as rotigotine transdermal patch, pramipexole, ropinirole, gabapentin enacarbil, pregabalin and gabapentin are effective in the short-term treatment of RLS and rotigotine, followed by gabapentin enacarbil, ropinirole, pramipexole and gabapentin for long-term treatment. Based on expert consensus, the recommendation for daily RLS is dopamine agonists or gabapentin or low-potency opioids. Levodopa is less preferred for treating daily RLS due to its high risk of augmentation. For intermittent RLS, it is levodopa or dopamine agonists or low-potency opioids or benzodiazepines. For refractory RLS, the choice is to change to gabapentin or a different dopamine agonist, addition of a second agent like gabapentin or benzodiazepine to the existing drug or changing to a high-potency opioid or tramadol. Medications with safety record in pregnancy include opioids and antiepileptics such as carbamazepine and gabapentin. There are concerns that patients with RLS are at risk for metabolic deregulation, autonomic dysfunction and cardiovascular morbidity. However, a recent study concluded that RLS is not associated with increased risk of cardiovascular complications.
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Affiliation(s)
- Kavitha Nagandla
- Department of Obstetrics and Gynecology, Melaka Manipal Medical College, Jalan Batu Hampar, Bukit Baru, Melaka, Malaysia.
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Garcia-Borreguero D, Ferini-Strambi L, Kohnen R, O'Keeffe S, Trenkwalder C, Högl B, Benes H, Jennum P, Partinen M, Fer D, Montagna P, Bassetti CL, Iranzo A, Sonka K, Williams AM. European guidelines on management of restless legs syndrome: report of a joint task force by the European Federation of Neurological Societies, the European Neurological Society and the European Sleep Research Society. Eur J Neurol 2012; 19:1385-96. [DOI: 10.1111/j.1468-1331.2012.03853.x] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 07/12/2012] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Ralf Kohnen
- RPS Research Germany and Psychology Department; University Erlangen-Nuremberg; Nuremberg Germany
| | - Shaun O'Keeffe
- Department of Geriatric Medicine; Galway University Hospitals; Galway Ireland
| | - Claudia Trenkwalder
- Paracelsus-Elena Klinik; Center of Parkinsonism and Movement Disorders; Kassel Germany
- Department of Clinical Neurophysiology; University of Goettingen; Kassel Germany
| | - Birgit Högl
- Department of Neurology; Innsbruck Medical University; Innsbruck Austria
| | - Heike Benes
- Somni Bene Institute for Medical Research and Sleep Medicine, and Neurology Department; University of Rostock; Schwerin Germany
| | - Poul Jennum
- Danish Center for Sleep Medicine; Glostrup Hospital, and Center for Healthy Aging; University of Copenhagen; Copenhagen Denmark
| | - Markku Partinen
- Helsinki Sleep Clinic; Vitalmed Research Centre; Helsinki Finland
| | | | - Pasquale Montagna
- Department of Neurological Sciences; University of Bologna; Bologna Italy
| | - Claudio L. Bassetti
- Department of Neurology; University Hospital (Inselspital), Bern, and Neurocenter of Southern Switzerland; Lugano Switzerland
| | - Alex Iranzo
- Neurology Service and Multidisciplinary Sleep Unit; Hospital Clinic; Barcelona Spain
- Centro de Investigación Biomédica en Red Enfermedades Neurodegenerativas (CIBERNED); Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Barcelona Spain
| | - Karel Sonka
- Department of Neurology; First Faculty of Medicine, Charles University; Prague Czech Republic
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Keeler BE, Baran CA, Brewer KL, Clemens S. Increased excitability of spinal pain reflexes and altered frequency-dependent modulation in the dopamine D3-receptor knockout mouse. Exp Neurol 2012; 238:273-83. [DOI: 10.1016/j.expneurol.2012.09.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 08/22/2012] [Accepted: 09/09/2012] [Indexed: 12/29/2022]
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Abstract
Restless legs syndrome (RLS) is a common neurological disorder of unknown etiology that is managed by therapy directed at relieving its symptoms. Treatment of patients with milder symptoms that occur intermittently may be treated with nonpharmacological therapy but when not successful, drug therapy should be chosen based on the timing of the symptoms and the needs of the patient. Patients with moderate to severe RLS typically require daily medication to control their symptoms. Although the dopamine agonists, ropinirole and pramipexole have been the drugs of choice for patients with moderate to severe RLS, drug emergent problems like augmentation may limit their use for long term therapy. Keeping the dopamine agonist dose as low as possible, using longer acting dopamine agonists such as the rotigotine patch and maintaining a high serum ferritin level may help prevent the development of augmentation. The α2δ anticonvulsants may now also be considered as drugs of choice for moderate to severe RLS patients. Opioids should be considered for RLS patients, especially for those who have failed other therapies since they are very effective for severe cases. When monitored appropriately, they can be very safe and durable for long term therapy. They should also be strongly considered for treating patients with augmentation as they are very effective for relieving the worsening symptoms that occur when decreasing or eliminating dopamine agonists.
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Aurora RN, Kristo DA, Bista SR, Rowley JA, Zak RS, Casey KR, Lamm CI, Tracy SL, Rosenberg RS. The treatment of restless legs syndrome and periodic limb movement disorder in adults--an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses: an American Academy of Sleep Medicine Clinical Practice Guideline. Sleep 2012; 35:1039-62. [PMID: 22851801 PMCID: PMC3397811 DOI: 10.5665/sleep.1988] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
A systematic literature review and meta-analyses (where appropriate) were performed to update the previous AASM practice parameters on the treatments, both dopaminergic and other, of RLS and PLMD. A considerable amount of literature has been published since these previous reviews were performed, necessitating an update of the corresponding practice parameters. Therapies with a STANDARD level of recommendation include pramipexole and ropinirole. Therapies with a GUIDELINE level of recommendation include levodopa with dopa decarboxylase inhibitor, opioids, gabapentin enacarbil, and cabergoline (which has additional caveats for use). Therapies with an OPTION level of recommendation include carbamazepine, gabapentin, pregabalin, clonidine, and for patients with low ferritin levels, iron supplementation. The committee recommends a STANDARD AGAINST the use of pergolide because of the risks of heart valve damage. Therapies for RLS secondary to ESRD, neuropathy, and superficial venous insufficiency are discussed. Lastly, therapies for PLMD are reviewed. However, it should be mentioned that because PLMD therapy typically mimics RLS therapy, the primary focus of this review is therapy for idiopathic RLS.
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Affiliation(s)
- R Nisha Aurora
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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