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Burini A, Pellitteri G, Merlino G, Nilo A, Tereshko Y, Dolso P, Gigli GL, Valente M. Current and emerging pharmaceutical strategies for the treatment and management of restless legs syndrome. Expert Rev Neurother 2024; 24:997-1009. [PMID: 39082506 DOI: 10.1080/14737175.2024.2385947] [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: 05/30/2024] [Accepted: 07/25/2024] [Indexed: 09/21/2024]
Abstract
INTRODUCTION Restless legs syndrome (RLS) is a sensory-motor sleep disorder that affects up to 13% of adults in the Western world and 2-4% of children. It impairs night sleep with an impact on daily performances and life quality. Thus, moderate-to-severe RLS requires pharmacological treatment. AREAS COVERED In the present review, which is based on PubMed searches with no time limits, the authors discuss the recommended pharmacotherapy for RLS in addition to other emerging treatment options. The authors provide coverage to the current recommendations for both adults and pediatric patients with RLS. EXPERT OPINION Current evidence suggests removing all causes of secondary RLS, including iron deficiency, chronic renal failure, drugs, and treating other sleep disorders that may worsen symptoms. Also, intermittent RLS should be addressed with behavioral measures and on-demand therapy. For chronic persistent RLS, α2δ calcium channel ligands are a first-line pharmacological approach, whereas dopamine agonists are associated with increased risk and should be spared. When RLS is refractory to first-line treatment, polytherapy, or opioid monotherapy should be considered. Nonetheless, some patients may not reach sustained symptom relief. Further research is needed to better understand the pathophysiology of RLS and to develop newer more effective drugs.
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Affiliation(s)
- Alessandra Burini
- Clinical Neurology, Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Gaia Pellitteri
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
- SOSD Stroke Unit, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Annacarmen Nilo
- Clinical Neurology, Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Yan Tereshko
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Pierluigi Dolso
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
| | - Gian Luigi Gigli
- Clinical Neurology, Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology, Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head-Neck and Neuroscience, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
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Scanga A, Lafontaine AL, Kaminska M. An overview of the effects of levodopa and dopaminergic agonists on sleep disorders in Parkinson's disease. J Clin Sleep Med 2023; 19:1133-1144. [PMID: 36716191 PMCID: PMC10235717 DOI: 10.5664/jcsm.10450] [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: 07/23/2022] [Revised: 12/09/2022] [Accepted: 12/09/2022] [Indexed: 01/31/2023]
Abstract
Sleep disorders are among the most common nonmotor symptoms in Parkinson's disease and are associated with reduced cognition and health-related quality of life. Disturbed sleep can often present in the prodromal or early stages of this neurodegenerative disease, rendering it crucial to manage and treat these symptoms. Levodopa and dopaminergic agonists are frequently prescribed to treat motor symptoms in Parkinson's disease, and there is increasing interest in how these pharmacological agents affect sleep and their effect on concomitant sleep disturbances and disorders. In this review, we discuss the role of dopamine in regulating the sleep-wake state and the impact of neurodegeneration on sleep. We provide an overview of the effects of levodopa and dopaminergic agonists on sleep architecture, insomnia, excessive daytime sleepiness, sleep-disordered breathing, rapid eye movement sleep behavior disorder, and restless legs syndrome in Parkinson's disease. Levodopa and dopaminergic drugs may have different effects, beneficial or adverse, depending on dosing, method of administration, and differential effects on the different dopamine receptors. Future research in this area should focus on elucidating the specific mechanisms by which these drugs affect sleep in order to better understand the pathophysiology of sleep disorders in Parkinson's disease and aid in developing suitable therapies and treatment regimens. CITATION Scanga A, Lafontaine A-L, Kaminska M. An overview of the effects of levodopa and dopaminergic agonists on sleep disorders in Parkinson's disease. J Clin Sleep Med. 2023;19(6):1133-1144.
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Affiliation(s)
- Amanda Scanga
- Division of Experimental Medicine, Glen Site, McGill University Health Centre, Montréal, Québec, Canada
| | - Anne-Louise Lafontaine
- Montreal Neurological Institute, McGill University Health Centre, Montréal, Québec, Canada
| | - Marta Kaminska
- Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
- Respiratory Division and Sleep Laboratory, McGill University Health Centre, Montréal, Québec, Canada
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3
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Yeung Laiwah J, Winkelman JW. How effective are treatment guidelines for augmented RLS? Sleep 2022; 45:6582621. [DOI: 10.1093/sleep/zsac108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/14/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Study Objectives
The objective of this study was to assess the effectiveness of current treatment guidelines for restless legs syndrome (RLS) augmentation in patients on dopamine agonists (DAs) which recommend a cross-titration strategy to an alpha-2-delta ligand (A2D) and/or opioid.
Methods
Consecutive new consultations for RLS with both augmentation and active treatment with DAs at the time of initial assessment were included if followed >5 months. Clinical information from the semi-structured initial consultation, and subsequent visits until their most recent/final visit was extracted. Clinical Global Impression-Severity (CGI-S) and Clinical Global Impression-Improvement (CGI-I) scores were retrospectively determined by two independent evaluators.
Results
In the 63 patients with augmented RLS on DAs, followed for 5–59 months (mean = 28, SD = 14), the average age was 67.6 (SD = 9.8) and 63% were female. Mean duration of prior dopaminergic therapy was 11.6 years (SD = 6.7) and average pramipexole equivalent dose was 1.23 mg (SD = 1.22 mg). At baseline, RLS was “moderate-markedly” severe (CGI-S = 4.9). At the final/most recent visit, 78% (49/63) were classified as Responders (CGI-I ≤ 2, “Much” or “Very Much Improved”) with an average CGI-S of 2.4 (“borderline-mildly ill”). Responders (59%) were more likely to have discontinued DAs than Non-Responders (40%), and mean opioid doses were higher in Responders (39 vs 20 MME). No differences in baseline DA dose, final A2D dose, or iron therapy were observed between groups. Responders did have significantly more severe RLS, more sleep maintenance insomnia, and greater subjective daytime sleepiness at baseline (p < 0.05).
Conclusions
Guideline-based management is effective in most patients with augmented RLS on DAs.
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Sparasci D, Rossinelli A, Ferri R, Cippà P, Rinaldi A, Manconi M. Severe restless legs syndrome in a family with Alport syndrome. BMC Nephrol 2021; 22:249. [PMID: 34225668 PMCID: PMC8256610 DOI: 10.1186/s12882-021-02455-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022] Open
Abstract
Background Restless legs syndrome (RLS) is a common sleep-related movement disorder characterized by an urge to move the legs during inactivity, especially at evening-night. RLS is highly prevalent in patients with kidney failure and have an impact on quality of life, mood, sleep quality and overall on compliance to the dialysis. Alport syndrome (AS) is a rare inherited disease, predominantly X-linked, secondary to mutations in genes encoding α3, α4 or α5 chains of type IV collagen, and characterized by hematuria, chronic kidney disease, neurosensory deafness, and lenticonus. Case presentation Here we describe a family with a combination of X-linked AS and severe RLS accompanied by periodic limb movements during sleep (PLMS). In the first patient we identified, RLS was complicated by a paradoxical response to dopamine agonists named “augmentation”, leading to sleep disruption, hallucinations and five peritoneal perforations during the peritoneal dialysis due to the difficulty to rest still. Therapeutic adjustments and renal transplantation improved RLS and PLMS. In two brothers, severe RLS prevented a compliance with hemodialysis. Female family members carrying the mutation were also affected by RLS, while those without the mutations were RLS-free. Conclusions RLS has not been reported earlier in association with AS, but the peculiar combinations observed in this family will stimulate further clinical studies and motivate nephrologists to seek for RLS symptoms and sleep disturbances in AS patients.
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Affiliation(s)
- Davide Sparasci
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland.
| | - Andrea Rossinelli
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | - Raffaele Ferri
- Sleep Research Centre, Oasi Research Institute - IRCCS, Troina, Italy
| | - Pietro Cippà
- Division of Nephrology, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Andrea Rinaldi
- Institute of Oncology Research, Faculty of Biomedical Sciences, Università della Svizzera italiana, 6500, Bellinzona, TI, Switzerland
| | - Mauro Manconi
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.,Department of Neurology, University Hospital, Inselspital, Bern, Switzerland
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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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Trenkwalder C, Paulus W. Pharmacological treatments of augmentation in restless legs syndrome patients. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2019; 84:255-265. [PMID: 31229175 DOI: 10.1016/bs.apha.2019.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Augmentation, a treatment-induced paradoxical worsening of the symptoms of restless legs syndrome (RLS) that is caused by long-term dopaminergic therapy, in particular with higher doses, remains the major challenge of RLS treatment. The mainstay of treatment continues to be preventing augmentation, either by starting RLS therapy with alternative drugs or by sensitizing physicians about the absolute necessity of respecting approved dosages of dopaminergic drugs when treating RLS and never exceeding the maximum recommended dosages. In the case of a positive diagnosis of augmentation, treatment consists of reducing or eliminating dopaminergic therapy, ensuring that serum ferritin is clearly higher than the level assumed to be necessary from a hematological point of view and/or switching treatment to alternative drugs such as α2δ ligands, opiates, or to combination therapy.
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Affiliation(s)
- Claudia Trenkwalder
- Department of Neurosurgery, University Medical Center, Göttingen, Germany; Paracelsus-Elena Hospital, Center of Parkinsonism and Movement Disorders, Kassel, Germany.
| | - Walter Paulus
- Department of Clinical Neurophysiology, University Medical Center Göttingen, Georg August University, Göttingen, Germany
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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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8
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Casoni F, Galbiati A, Ferini-Strambi L. D3 receptor agonist efficacy in restless legs syndrome. PHARMACOLOGY OF RESTLESS LEGS SYNDROME (RLS) 2019; 84:21-35. [DOI: 10.1016/bs.apha.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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9
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Garcia-Borreguero D, Cano-Pumarega I, Marulanda R. Management of treatment failure in restless legs syndrome (Willis-Ekbom disease). Sleep Med Rev 2018; 41:50-60. [DOI: 10.1016/j.smrv.2018.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 12/16/2017] [Accepted: 01/02/2018] [Indexed: 10/18/2022]
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10
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Steinke SS, Trenkwalder C, Zimmermann J, Sixel-Döring F, Muntean ML. Polysomnographic findings in restless legs syndrome (RLS) patients with severe augmentation. Sleep Med 2018; 48:79-85. [DOI: 10.1016/j.sleep.2018.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/22/2018] [Accepted: 04/25/2018] [Indexed: 10/17/2022]
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Leu-Semenescu S, Petiau C, Charley Monaca C, Dauvilliers Y. French consensus: Augmentation syndrome in restless legs syndrome. Rev Neurol (Paris) 2018; 174:532-539. [PMID: 30055794 DOI: 10.1016/j.neurol.2018.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/16/2018] [Accepted: 06/05/2018] [Indexed: 11/19/2022]
Abstract
Augmentation syndrome is one of the most severe complications of RLS. It is characterised by a worsening of treated symptoms; principally an increase in the severity of symptoms and an earlier onset time. Augmentation syndrome occurs primarily with dopaminergic treatments. It is crucial for the patient to be sufficiently well informed to prevent its occurrence and the prescription of too high doses of dopaminergic agonists avoided. In the presence of augmentation syndrome confirmed using the diagnostic criteria, the specialist treating the restless legs syndrome should quickly modify the patient's treatment. In this article, our expert group proposes a practical strategy for the diagnosis, prevention and treatment of augmentation syndrome.
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Affiliation(s)
- S Leu-Semenescu
- Narcolepsy and Idiopathic Hypersomnia National Reference Centre, 75000 Paris, France; Sleep pathologies Service, Pitié-Salpêtrière/Charles-Foix, AP-HP Hospital Group, 75651 Paris cedex 13, France; The Brain and Spinal Institute Research Centre, UPMC Paris 6, Inserm U1127, CNRS UMR7225, 75000 Paris, France.
| | - C Petiau
- Sainte-Barbe Clinical Sleep Centre, Saint-Vincent Hospital Group, 67000 Strasbourg, France
| | - C Charley Monaca
- Clinical Neurophysiology, Teaching Hospital, Lille University, Inserm UMR 1171, 59037 Lille, France
| | - Y Dauvilliers
- Narcolepsy and Idiopathic Hypersomnia National Reference Centre, 75000 Paris, France; Neurology Department, Sleep disorders Unit, Gui-De-Chauliac Hospital, 34295 Montpellier, France; Inserm U1061, UM1, 34295 Montpellier, France
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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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13
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Trenkwalder C, Canelo M, Lang M, Schroeder H, Kelling D, Berkels R, Schollmayer E, Heidbrede T, Benes H. Management of augmentation of restless legs syndrome with rotigotine: a 1-year observational study. Sleep Med 2017; 30:257-265. [DOI: 10.1016/j.sleep.2015.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 10/20/2015] [Accepted: 10/27/2015] [Indexed: 11/26/2022]
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14
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Winkelman JW, Mackie SE, Mei LA, Platt S, Schoerning L. A method to switch from oral dopamine agonists to rotigotine in patients with restless legs syndrome and mild augmentation. Sleep Med 2016; 24:18-23. [PMID: 27810181 DOI: 10.1016/j.sleep.2016.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/12/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND We examined the short- and long-term efficacy and tolerability of a cross-titration algorithm from oral dopamine agonists to the rotigotine transdermal patch in patients dissatisfied with their restless legs syndrome (RLS) treatment, predominantly with mild augmentation. METHODS Patients with RLS (n = 20) were recruited at a single site. The cross-titration consisted of decreasing oral dopaminergic agents (ropinirole by 1 mg or pramipexole by 0.25 mg) and increasing rotigotine by 1 mg every two days. Efficacy and adverse events (AEs) were assessed at one, three, six and 12 months after the switch. RESULTS Patients had moderate-severe RLS symptoms at the baseline (mean international restless legs syndrome (IRLS) score 19.4 ± 5.5); 85% had augmentation and 45% reported afternoon RLS symptoms. The baseline mean pramipexole equivalent dose was 0.6 ± 0.3 mg. At Week 5, 85% (17/20) had successfully switched from their oral dopamine agonist to rotigotine (mean dose 2.5 ± 0.6 mg; change in IRLS score: -6.7 ± 8.4, p = 0.002); 14 patients were CGI-I responders (much or very much improved). Three patients withdrew due to lack of efficacy. Twelve months after cross-titration, 10 patients continued on rotigotine, of whom four required either higher doses of rotigotine or supplemental RLS medication compared with their optimal Week 5 dose; five patients withdrew due to AEs and two due to lack of efficacy. CONCLUSION A cross-titration to rotigotine was efficacious after five weeks in 70% of patients dissatisfied with RLS treatment, most of whom had mild augmentation. At one year following the medication switch, 50% had discontinued rotigotine due to lack of continued efficacy or side effects.
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Affiliation(s)
- John W Winkelman
- Departments of Psychiatry and Neurology, Massachusetts General Hospital, Harvard Medical School, 1 Bowdoin Square, Boston, MA 02114, USA.
| | - Susan E Mackie
- Departments of Psychiatry and Neurology, Massachusetts General Hospital, Harvard Medical School, 1 Bowdoin Square, Boston, MA 02114, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Leslie A Mei
- Massachusetts General Hospital, 1 Bowdoin Square, Boston, MA 02114, USA
| | - Samuel Platt
- Massachusetts General Hospital, 1 Bowdoin Square, Boston, MA 02114, USA
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Mayer SB, Levy JR, Farrell-Carnahan L, Nichols MG, Raman S. Obese Veterans Enrolled in a Veterans Affairs Medical Center Outpatient Weight Loss Clinic Are Likely to Experience Disordered Sleep and Posttraumatic Stress. J Clin Sleep Med 2016; 12:997-1002. [PMID: 27070244 DOI: 10.5664/jcsm.5934] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 02/15/2016] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVES This cross-sectional study aimed to characterize sleep patterns, the quality and duration of sleep, and estimate the prevalence of common sleep disorders and posttraumatic stress disorder (PTSD) in a hospital-based Veterans Affairs MOVE! (Managing Overweight Veterans Everywhere) clinic. METHODS Participants completed five instruments: the Pittsburgh Sleep Quality Index (PSQI), Smith's Measure of Morningness/Eveningness, Restless Legs Syndrome Rating Scale, the STOP Questionnaire, and the Posttraumatic Stress Disorder (PTSD) Checklist - Civilian Version (PCL-C). RESULTS Enrolled Veterans (n = 96) were mostly male (78%), African American (49%), mean age 58 (standard deviation [SD] 10.6) years, and mean body mass index (BMI) 38.4 kg/m(2) (SD 8.4). By PSQI, 89% rated sleep quality as "poor" (mean = 11.1, SD = 5.1), consistent with severely impaired sleep. Most were at high risk for sleep disorders including restless leg syndrome (53%), obstructive sleep apnea (66%), and circadian sleep disorders (72%). Forty-seven percent endorsed clinically significant symptoms of PTSD. Hypotheses-generating regression models suggest sleep latency (minutes before falling asleep) was associated with BMI (p = 0.018). Bedtime, getting up time, hours of sleep, waking up in the middle of the night or early morning, having to get up to use the bathroom, inability to breathe comfortably, cough or snore loudly, feeling too cold or too hot, having bad dreams, pain, and frequency of having trouble sleeping, were not significantly associated with BMI. CONCLUSIONS Our cross-sectional study suggests that sleep difficulties are common among Veterans referred to a weight loss program at a Veterans Affairs Hospital. Controlled studies are needed to investigate whether the results are generalizable and whether obesity among veterans is a risk factor for sleep disorders and PTSD. COMMENTARY A commentary on this article appears in this issue on page 943.
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Affiliation(s)
- Stephanie B Mayer
- Department of Medicine, Division of Endocrinology, Virginia Commonwealth University, Richmond VA.,Department of Medicine Division of Endocrinology Hunter Holmes McGuire VAMC, Richmond VA
| | - James R Levy
- Department of Medicine, Division of Endocrinology, Virginia Commonwealth University, Richmond VA.,Department of Medicine Division of Endocrinology Hunter Holmes McGuire VAMC, Richmond VA
| | | | - Michelle G Nichols
- Department of Research, Hunter Holmes McGuire VAMC, Richmond VA.,College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Shekar Raman
- Department of Neurology Hunter Holmes McGuire VAMC, Richmond VA
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16
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de Biase S, Merlino G, Valente M, Gigli GL. Opioids in the treatment of restless legs syndrome: pharmacological and clinical aspects. Expert Opin Drug Metab Toxicol 2016; 12:1035-45. [PMID: 27310338 DOI: 10.1080/17425255.2016.1198320] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Stefano de Biase
- Neurology Unit, Department of Experimental and Clinical Medical Sciences, University of Udine Medical School, Udine, Italy
| | - Giovanni Merlino
- Department of Neurosciences, ‘S. Maria della Misericordia’ University Hospital, Udine, Italy
| | - Mariarosaria Valente
- Neurology Unit, Department of Experimental and Clinical Medical Sciences, University of Udine Medical School, Udine, Italy
- Department of Neurosciences, ‘S. Maria della Misericordia’ University Hospital, Udine, Italy
| | - Gian Luigi Gigli
- Neurology Unit, Department of Experimental and Clinical Medical Sciences, University of Udine Medical School, Udine, Italy
- Department of Neurosciences, ‘S. Maria della Misericordia’ University Hospital, Udine, Italy
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17
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Ferini-Strambi L, Marelli S, Galbiati A. Clinical pharmacology and efficacy of rotigotine (Neupro® patch) in the treatment of restless leg syndrome. Expert Opin Drug Metab Toxicol 2016; 12:967-75. [DOI: 10.1080/17425255.2016.1194393] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Luigi Ferini-Strambi
- Division of Neuroscience, Sleep Disorders Center, Ospedale San Raffaele and Università Vita-Salute San Raffaele, Milan, Italy
| | - Sara Marelli
- Division of Neuroscience, Sleep Disorders Center, Ospedale San Raffaele and Università Vita-Salute San Raffaele, Milan, Italy
| | - Andrea Galbiati
- Division of Neuroscience, Sleep Disorders Center, Ospedale San Raffaele and Università Vita-Salute San Raffaele, Milan, Italy
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Garcia-Borreguero D, Silber MH, Winkelman JW, Högl B, Bainbridge J, Buchfuhrer M, Hadjigeorgiou G, Inoue Y, Manconi M, Oertel W, Ondo W, Winkelmann J, Allen RP. Guidelines for the first-line treatment of restless legs syndrome/Willis-Ekbom disease, prevention and treatment of dopaminergic augmentation: a combined task force of the IRLSSG, EURLSSG, and the RLS-foundation. Sleep Med 2016; 21:1-11. [PMID: 27448465 DOI: 10.1016/j.sleep.2016.01.017] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Revised: 01/09/2016] [Accepted: 01/12/2016] [Indexed: 10/22/2022]
Abstract
A Task Force was established by the International Restless Legs Syndrome Study Group (IRLSSG) in conjunction with the European Restless Legs Syndrome Study Group (EURLSSG) and the RLS Foundation (RLS-F) to develop evidence-based and consensus-based recommendations for the prevention and treatment of long-term pharmacologic treatment of dopaminergic-induced augmentation in restless legs syndrome/Willis-Ekbom disease (RLS/WED). The Task Force made the following prevention and treatment recommendations: As a means to prevent augmentation, medications such as α2δ ligands may be considered for initial RLS/WED treatment; these drugs are effective and have little risk of augmentation. Alternatively, if dopaminergic drugs are elected as initial treatment, then the daily dose should be as low as possible and not exceed that recommended for RLS/WED treatment. However, the physician should be aware that even low dose dopaminergics can cause augmentation. Patients with low iron stores should be given appropriate iron supplementation. Daily treatment by either medication should start only when symptoms have a significant impact on quality of life in terms of frequency and severity; intermittent treatment might be considered in intermediate cases. Treatment of existing augmentation should be initiated, where possible, with the elimination/correction of extrinsic exacerbating factors (iron levels, antidepressants, antihistamines, etc.). In cases of mild augmentation, dopamine agonist therapy can be continued by dividing or advancing the dose, or increasing the dose if there are breakthrough night-time symptoms. Alternatively, the patient can be switched to an α2δ ligand or rotigotine. For severe augmentation the patient can be switched either to an α2δ ligand or rotigotine, noting that rotigotine may also produce augmentation at higher doses with long-term use. In more severe cases of augmentation an opioid may be considered, bypassing α2δ ligands and rotigotine.
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Affiliation(s)
| | - Michael H Silber
- Center for Sleep Medicine and Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - John W Winkelman
- Harvard Medical School, Boston, MA, USA; Departments of Psychiatry and Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Birgit Högl
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Jacquelyn Bainbridge
- Departments of Clinical Pharmacy and Neurology, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences and School of Medicine, Aurora, CO, USA
| | - Mark Buchfuhrer
- Stanford University School of Medicine, Stanford, CA, USA; Private Practice, Downey, CA, USA
| | - Georgios Hadjigeorgiou
- Department of Neurology, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Yuichi Inoue
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan; Department of Somnology, Tokyo Medical University, Tokyo, Japan
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital, Lugano, Switzerland
| | - Wolfgang Oertel
- Department of Neurology, Philipps-Universität Marburg, Marburg, Germany
| | - William Ondo
- Department of Neurology, Methodist Neuroscience Institute, Houston, TX, USA
| | - Juliane Winkelmann
- Helmholtz Zentrum München, Institute of Neurogenomics, Munich, Germany; Department of Neurology, 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, MD, USA; Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
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Liu GJ, Wu L, Wang SL, Ding L, Xu LL, Wang YF, Chang LY. Incidence of Augmentation in Primary Restless Legs Syndrome Patients May Not Be That High: Evidence From A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e2504. [PMID: 26765466 PMCID: PMC4718292 DOI: 10.1097/md.0000000000002504] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Augmentation is a common complication of primary restless legs syndrome (RLS) during treatment; however, its incidence rate remains unclear.The aim of this study is investigate the rate of augmentation during RLS treatment.We searched 6 databases, including PubMed, OVID, Embase, Wiley citations, Web of Science research platform (including SciELO Citation Index, Medline, KCI Korean Journal Database, the Web of Science™ Core Collection), and the Cochrane library, and screened the reference lists of the included trials and recently published reviews.Randomized controlled trials and observational studies that reported augmentation events during RLS treatment.Primary RLS patients older than 18 years.No restrictions regarding intervention types were applied.Three investigators independently extracted and pooled the data to analyze the augmentation rate of the total sample and of patient subgroups with different interventions, treatment durations and drug regimens and different geographic origins. Fixed-effects or random-effects model was used for pooled analysis.A total of 60 studies involving 11,543 participants suggested an overall augmentation rate of 5.6% (95% confidence intervals (CI), 4.0-7.7). The augmentation incidence was 6.1% (95% CI, 4.1-9.1) for long-term treatment and 3.3% (95% CI, 1.4-7.3) for short-term treatment. In addition, 27.1% (95% CI, 12.3-49.5) of the levodopa-treated patients, 6.0% (95% CI, 4.1-8.8) of the patients treated with dopamine agonists, and 0.9% (95% CI, 0.2-3.3) of the patients taking pregabalin or gabapentin developed augmentation. Augmentation occurred in 7.2% (95% CI, 5.0-10.3) of the patients taking immediate-release drugs and in 1.7% (95% CI, 0.6-5.0) of the patients taking transdermal application.The main limitations are that the augmentation rates were not evaluated according to drug dosage, gender, and age and symptom severity.Approximately 5 to 6 in 100 RLS patients developed augmentation during treatment.
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Affiliation(s)
- Guang Jian Liu
- From the Department of Neurology, Taihe Hospital Affiliated to Hubei University of Medicine, Shiyan City, Hubei Province, China (GJL, SLW, LD, LLX, YFW); Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt University School of Medicine, Nashville, TN (LW); Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN (LW); and Department of Neurology, Xiangyang Center Hospital Affiliated to Hubei University of Arts and Science, Xiangyang City, Hubei Province, China (LYC)
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de Biase S, Valente M, Gigli GL. Intractable restless legs syndrome: role of prolonged-release oxycodone-naloxone. Neuropsychiatr Dis Treat 2016; 12:417-25. [PMID: 26966363 PMCID: PMC4770072 DOI: 10.2147/ndt.s81186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Restless legs syndrome (RLS) is a common neurological disorder characterized by an irresistible urge to move the legs accompanied by uncomfortable sensations that occur at night or at time of rest. Pharmacological therapy should be limited to patients who suffer from clinically relevant symptoms. Chronic RLS is usually treated with either a dopamine agonist (pramipexole, ropinirole, rotigotine) or an α2δ calcium-channel ligand (gabapentin, gabapentin enacarbil, pregabalin). Augmentation is the main complication of long-term dopaminergic treatment, and frequently requires a reduction of current dopaminergic dose or a switch to non-dopaminergic medications. Opioids as monotherapy or add-on treatment should be considered when alternative satisfactory regimens are unavailable and the severity of symptoms warrants it. In a recent Phase III trial, oxycodone-naloxone prolonged release (PR) demonstrated a significant and sustained effect on patients with severe RLS inadequately controlled by previous treatments. The adverse-event profile was consistent with the safety profile of opioids. The most frequent adverse events were fatigue, constipation, nausea, headache, hyperhidrosis, somnolence, dry mouth, and pruritus. Adverse events were usually mild or moderate in intensity. No cases of augmentation were reported. Oxycodone-naloxone PR is approved for the second-line symptomatic treatment of adults with severe to very severe idiopathic RLS after failure of dopaminergic treatment. Further studies are needed to evaluate if oxycodone-naloxone PR is equally efficacious as a first-line treatment. Moreover, long-term comparative studies between opioids, dopaminergic drugs and α2δ ligands are needed.
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Affiliation(s)
- Stefano de Biase
- Neurology Unit, Department of Experimental and Clinical Medical Sciences, University of Udine Medical School, Udine, Italy
| | - Mariarosaria Valente
- Neurology Unit, Department of Experimental and Clinical Medical Sciences, University of Udine Medical School, Udine, Italy; Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Gian Luigi Gigli
- Neurology Unit, Department of Experimental and Clinical Medical Sciences, University of Udine Medical School, Udine, Italy; Department of Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
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21
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Trotti LM. Toward a Definition of Quality Care for Patients with Restless Legs Syndrome. Sleep Med Clin 2015; 10:293-301, xiii. [DOI: 10.1016/j.jsmc.2015.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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22
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Zak RS, Walters AS. Dopaminergic Therapy for Restless Legs Syndrome/Willis-Ekbom Disease. Sleep Med Clin 2015; 10:279-85, xiii. [DOI: 10.1016/j.jsmc.2015.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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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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Garcia-Borreguero D, Benitez A, Kohnen R, Allen R. Augmentation of restless leg syndrome (Willis-Ekbom disease) during long-term dopaminergic treatment. Postgrad Med 2015; 127:716-25. [PMID: 26077324 DOI: 10.1080/00325481.2015.1058140] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Restless legs syndrome (RLS), also known as Willis-Ekbom disease (WED), is a common sensorimotor disorder that can generally be effectively managed in the primary care clinic. However, some treatment complications may arise. According to the recommendations of the International Restless Legs Syndrome Study Group, non-ergot dopamine-receptor agonists have over the past years been one of the first-line treatments for patients with RLS/WED requiring pharmacological therapy. Augmentation is the main complication of long-term dopaminergic treatment of RLS/WED and is defined as an overall worsening of symptoms beyond pretreatment levels in patients who experienced an initial positive therapeutic response. Once identified on the basis of its characteristic clinical features, augmentation requires careful management. In order to provide clinicians with a comprehensive understanding of this common treatment complication, this review discusses the clinical features of augmentation, and its differentiation from morning rebound, symptom fluctuations and natural disease progression. Reported incidences of augmentation in clinical trials of dopaminergic RLS/WED therapies are summarized. Finally, the hypothetical pathophysiology of augmentation and the current recommendations for management of patients with augmented RLS/WED symptoms are discussed.
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Long-Term Treatment of Restless Legs Syndrome (RLS): An Approach to Management of Worsening Symptoms, Loss of Efficacy, and Augmentation. CNS Drugs 2015; 29:351-7. [PMID: 26045290 DOI: 10.1007/s40263-015-0250-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Restless legs syndrome (RLS) is a common, frequently chronic, sensorimotor neurological disorder characterized by nocturnal leg dysesthesias and an irresistible urge to move the legs, usually resulting in sleep disturbance. Dopaminergic agonists, alpha-2-delta calcium-channel ligands, and opioids have all demonstrated efficacy to relieve symptoms of RLS and improve sleep. However, long-term treatment with dopamine agonists (the most commonly prescribed agents) is often characterized by worsening symptoms and loss of efficacy. A more worrisome complication of dopaminergic agents is augmentation, an iatrogenic worsening of RLS symptoms that can produce progressively more severe symptoms resulting in around-the-clock restlessness and near sleeplessness. Recent research has yielded consensus regarding a precise definition of augmentation and has contributed to improved knowledge regarding strategies for preventing this complication. When RLS symptoms worsen during the course of treatment, the clinician must consider the myriad of environmental, medical, pharmacologic, and psychiatric factors that can exacerbate RLS. In the absence of fully developed, evidence-based guidelines there remains uncertainty regarding the optimal management strategy if augmentation develops. However, we discuss several key principles based on the available published data and the authors' clinical experience. We also explore the recent increasing interest in alternative initial treatment strategies that avoid dopamine agonists and their associated complications altogether.
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26
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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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27
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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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