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Jahani Kondori M, Kolla BP, Moore KM, Mansukhani MP. Management of Restless Legs Syndrome in Pregnancy and Lactation. J Prim Care Community Health 2021; 11:2150132720905950. [PMID: 32054396 PMCID: PMC7025421 DOI: 10.1177/2150132720905950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Restless legs syndrome (RLS) affects about 20% of all pregnant women. RLS symptoms are usually moderate to severe in intensity during pregnancy and can result in insomnia, depression, and other adverse outcomes. Although iron deficiency has been implicated as a potential etiological factor, other mechanisms can also play a role. Nonpharmacologic methods are the primary recommended form of treatment for RLS in pregnancy and lactation. Iron supplementation may be considered when the serum ferritin is low; however, several patients are unable to tolerate iron or have severe symptoms despite oral iron replacement. Here, we describe a case of severe RLS in pregnancy and illustrate the dilemmas in diagnosis and management. We review the literature on the prevalence, diagnosis, course, possible underlying pathophysiologic mechanisms and complications of RLS in pregnancy. We describe current best evidence on the efficacy, and safety of nonpharmacologic therapies, oral and intravenous iron supplementation, as well as other medication treatments for RLS in pregnancy and lactation. We highlight gaps in the literature and provide a practical guide for the clinical management of RLS in pregnancy and during breastfeeding.
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Abstract
Restless legs syndrome (RLS), with a lifetime prevalence of up to 10%, is a frequent neurological disease and the most common movement disorder in sleep. A compulsive urge to move the legs with sensory symptoms and sleep disturbances can significantly impair the quality of life. Furthermore, RLS frequently occurs as a comorbidity to various internal and neurological diseases. It is diagnosed clinically based on the five essential diagnostic criteria. For treatment, an iron deficiency should first be excluded. Drugs approved for the treatment of RLS include dopaminergics (L-DOPA/benserazide) and dopamine agonists as well as oxycodone/naloxone, as a second-line treatment in severe cases. Augmentation as a deterioration of symptoms is a clinically defined complication of high-dose dopaminergic treatment, requiring special management strategies. Due to its high prevalence of up to 25%, RLS plays also an important role in the care of pregnant women.
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Restless-legs-Syndrom: ein Update. SOMNOLOGIE 2020. [DOI: 10.1007/s11818-020-00283-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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4
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Steinweg K, Nippita T, Cistulli PA, Bin YS. Maternal and neonatal outcomes associated with restless legs syndrome in pregnancy: A systematic review. Sleep Med Rev 2020; 54:101359. [PMID: 32805557 DOI: 10.1016/j.smrv.2020.101359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/19/2020] [Accepted: 05/19/2020] [Indexed: 10/23/2022]
Abstract
Restless legs syndrome (RLS) affects one in five pregnant women. This review aims to synthesise evidence regarding gestational RLS and its consequences on pregnant women and neonates. Search of Embase, MEDLINE, PsycINFO, Maternity and Infant Care and Scopus was conducted in July 2018 using MeSH headings and keywords for 'restless legs syndrome' and 'pregnancy' or 'birth'. Our search identified 16 eligible studies from 12 countries published between 2004 and 2018 concerning gestational RLS and one or more maternal, delivery or neonatal outcomes. The most consistent associations were observed between gestational RLS and increased risks of gestational hypertension, pre-eclampsia, and peripartum depression. There were mixed findings for caesarean delivery, preterm birth and low birth weight, with the majority reporting no association with gestational RLS. Gestational RLS was not associated with postpartum haemorrhage, gestational diabetes, fetal distress, or low Apgar scores. Future research is needed to investigate whether effective treatment of RLS can mitigate these potential harms. Validated methods for diagnosing RLS in pregnancy would support research in this growing field.
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Affiliation(s)
- Kate Steinweg
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Tanya Nippita
- Sydney Medical School Northern, University of Sydney, NSW, Australia; Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, NSW, Australia; Women and Babies Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Peter A Cistulli
- Sydney Medical School Northern, University of Sydney, NSW, Australia; Sleep Research Group, Charles Perkins Centre, University of Sydney, NSW, Australia; Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Yu Sun Bin
- Sydney Medical School Northern, University of Sydney, NSW, Australia; Sleep Research Group, Charles Perkins Centre, University of Sydney, NSW, Australia.
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Leung W, Singh I, McWilliams S, Stockler S, Ipsiroglu OS. Iron deficiency and sleep – A scoping review. Sleep Med Rev 2020; 51:101274. [DOI: 10.1016/j.smrv.2020.101274] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 12/11/2019] [Accepted: 12/15/2019] [Indexed: 12/16/2022]
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Abstract
Intravenous ferric carboxymaltose (Ferinject®; Injectafer®) is a colloidal solution of nanoparticles which consist of a polynuclear iron (III)-(oxyhydr)oxide core stabilized by carboxymaltose and may be given as a single high-dose, 15-min infusion. This article reviews the clinical use of ferric carboxymaltose in various patient populations with iron deficiency (ID) [± anaemia] and briefly summarizes its pharmacological properties. Based on extensive experience in the clinical trial and real-world settings, ferric carboxymaltose is an effective and generally well tolerated treatment for rapidly replenishing iron stores and correcting anaemia in patients with ID (± anaemia) of various aetiologies, including patients with chronic heart failure (CHF), chronic kidney disease, inflammatory bowel disease or perioperative anaemia, and women with ID during pregnancy, postpartum or associated with heavy uterine bleeding. As it may be given as a single high-dose infusion, ferric carboxymaltose has the potential to provide cost savings from a healthpayer perspective. Thus, ferric carboxymaltose remains an important option for the treatment of ID in adults and, where approved, children aged ≥ 14 years, when oral iron preparations are ineffective or cannot be used.
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Affiliation(s)
- Lesley J Scott
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Yang X, Yang B, Ming M, Li S, Wang F, Zhu Z, Ji C, Long J, Hu F, Xu Z, Ren H, Liu B. Efficacy and tolerability of intravenous iron for patients with restless legs syndrome: evidence from randomized trials and observational studies. Sleep Med 2019; 61:110-117. [PMID: 31395522 DOI: 10.1016/j.sleep.2019.01.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/11/2018] [Accepted: 01/08/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Restless legs syndrome (RLS) is a common neurological disorder of unclear pathophysiology that appears to involve an iron deficiency in the brain. Some studies, but not others, suggest that intravenous injection of iron can reduce RLS severity. METHOD The databases Web of Science, PubMed, Embase, Chinese National Knowledge Infrastructure, Wanfang, and SinoMed were searched for randomized controlled trials, cohort studies and case-control studies of intravenous iron therapy to treat RLS. Eligible studies were meta-analyzed using Stata 12.0. RESULTS This analysis indicated that IV iron was more efficacious than placebo in treating RLS (OR: 4.71,95%CI 4.21-5.21,p < 0.0001). According to sub-group analysis, either IV ferric carboxymaltose (FCM) or iron sucrose was more efficacious than placebo in treating RLS. Adverse events did not differ significantly between patients receiving intravenous iron or placebo (OR 1.68, 95%CI 0.92-3.07, p = 0.093). The present study also indicated after accepting IV iron treatment the IRLS score in RLS patients decreased (OR = 6.75,95%CI 4.02-9.49, p < 0.0001). The subgroup analysis showed that IV iron dextran, iron sucrose, and FCM could alleviate the IRLS score. CONCLUSION The available evidence suggests that intravenous iron is effective and tolerable for patients with RLS regardless of peripheral iron status.
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Affiliation(s)
- Xinglong Yang
- Department of Geriatric Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, 650032, PR China
| | - Baiyuan Yang
- Department of Neurology, Seventh People's Hospital of Chengdu, 610041, PR China
| | - Mao Ming
- Department of Emergency Internal Medicine Guang'an Men South Area Hospital, China Academy of Chinese Medical Sciences, 102600, PR China
| | - Shimei Li
- Department of Anesthesia, Kunming Xishan District People's Hospital, Kunming, Yunnan Province, 650100, PR China
| | - Fang Wang
- Department of Geriatric Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, 650032, PR China
| | - Zhigang Zhu
- Department of Geriatric Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, 650032, PR China
| | - Chang Ji
- Department of Geriatric Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, 650032, PR China
| | - Juan Long
- Department of Geriatric Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, 650032, PR China
| | - Fayun Hu
- Department of Neurology, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, Sichuan Province, 610041, PR China
| | - Zhong Xu
- Department of Geriatric Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, 650032, PR China
| | - Hui Ren
- Department of Geriatric Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, 650032, PR China.
| | - Bin Liu
- Department of Geriatric Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, 650032, PR China.
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Owais S, Chow CHT, Furtado M, Frey BN, Van Lieshout RJ. Non-pharmacological interventions for improving postpartum maternal sleep: A systematic review and meta-analysis. Sleep Med Rev 2018; 41:87-100. [PMID: 29449122 DOI: 10.1016/j.smrv.2018.01.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 01/04/2018] [Accepted: 01/17/2018] [Indexed: 12/29/2022]
Abstract
Evidence suggests that poor postpartum sleep quality is a risk factor for the development of postpartum depression. As such, non-pharmacological interventions have been developed to help improve sleep in the postpartum period. The primary aims of this systematic review and meta-analysis were to determine if non-pharmacological interventions improved maternal sleep and to compare the effectiveness of different intervention types. Secondary aims included examining effects on maternal mood and infant sleep. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from their inceptions to September 2017 and found 15 eligible studies. Non-pharmacological sleep interventions were found to improve subjective reports of maternal sleep (Cohen's d = -0.54, 95%CI = -0.88 to -0.19). Massage (Cohen's d = -1.07 95%CI = -1.34 to -0.79) and exercise (Cohen's d = -0.82 95%CI = -1.28 to -0.37) interventions had the largest impact on maternal sleep quality. Positive effects on nocturnal infant sleep were found for interventions overall (Cohen's d = -0.27 95%CI = -0.52 to -0.02) but not for maternal depression (Cohen's d = -0.08 95%CI = -0.28 to 0.12). Despite evidence suggesting improvements in subjective maternal sleep, more research must be conducted on the durability of effects of non-pharmacological interventions using objective measures of sleep quality.
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Affiliation(s)
- Sawayra Owais
- MiNDS Neuroscience Graduate Program, McMaster University, Ontario, Canada; Women's Health Concerns Clinic, St. Joseph's Healthcare Hamilton, Ontario, Canada
| | - Cheryl H T Chow
- Department of Psychology, Neuroscience and Behaviour, McMaster University, Ontario, Canada
| | - Melissa Furtado
- MiNDS Neuroscience Graduate Program, McMaster University, Ontario, Canada; Women's Health Concerns Clinic, St. Joseph's Healthcare Hamilton, Ontario, Canada
| | - Benicio N Frey
- MiNDS Neuroscience Graduate Program, McMaster University, Ontario, Canada; Women's Health Concerns Clinic, St. Joseph's Healthcare Hamilton, Ontario, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, Canada; Mood Disorders Program, St. Joseph's Healthcare Hamilton, Ontario, Canada
| | - Ryan J Van Lieshout
- MiNDS Neuroscience Graduate Program, McMaster University, Ontario, Canada; Women's Health Concerns Clinic, St. Joseph's Healthcare Hamilton, Ontario, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, Canada.
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9
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Zucconi M, Galbiati A, Rinaldi F, Casoni F, Ferini-Strambi L. An update on the treatment of Restless Legs Syndrome/Willis-Ekbom Disease: prospects and challenges. Expert Rev Neurother 2018; 18:705-713. [PMID: 30095315 DOI: 10.1080/14737175.2018.1510773] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Restless Legs Syndrome/Willis-Ekbom Disease (RLS/WED) is a sleep disorder characterized by an urge to move the legs, frequently associated or triggered by unpleasant sensations in the lower limbs that affects approximately 2.5% of adults. Therapy and management of RLS/WED require long-term interventions, since the typical manifestation of this disorder is chronic. Areas covered: In this review, we provide an update regarding the treatment of RLS/WED with particular attention to future challenges for its management. We reviewed a large variety of treatments studied in clinical trials and supported by the most updated guidelines. Alongside with first-line interventions other pharmacological options including opioids, benzodiazepines, iron therapy, and newly studied drugs are discussed. Furthermore, due to the occurrence of augmentation and worsening of symptoms we also reviewed the development of non-pharmacologic alternatives. Expert commentary: The management of RLS/WED is a challenge because of different long-term issues. Several complications, such as loss of the therapeutic effect of dopaminergic or non-dopaminergic agents and augmentation, are still unsolved concerns. However, the development of new drugs acting on adenosinergic and glutamatergic neurotransmission seems promising. Randomized controlled trials are needed in order to recognize effectiveness of new drugs or non-pharmacological treatment strategies.
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Affiliation(s)
- Marco Zucconi
- a Department of Clinical Neurosciences, Neurology - Sleep Disorders Center , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Andrea Galbiati
- a Department of Clinical Neurosciences, Neurology - Sleep Disorders Center , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Faculty of Psychology , "Vita-Salute" San Raffaele University , Milan , Italy
| | - Fabrizio Rinaldi
- a Department of Clinical Neurosciences, Neurology - Sleep Disorders Center , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Francesca Casoni
- a Department of Clinical Neurosciences, Neurology - Sleep Disorders Center , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Luigi Ferini-Strambi
- a Department of Clinical Neurosciences, Neurology - Sleep Disorders Center , IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Faculty of Psychology , "Vita-Salute" San Raffaele University , Milan , Italy
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10
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Tandon R, Jain A, Malhotra P. Management of Iron Deficiency Anemia in Pregnancy in India. Indian J Hematol Blood Transfus 2018; 34:204-215. [PMID: 29622861 PMCID: PMC5885006 DOI: 10.1007/s12288-018-0949-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/08/2018] [Indexed: 01/28/2023] Open
Abstract
Iron deficiency anemia (IDA) continues to be the commonest etiology of anemia in pregnancy. The prevalence of iron deficiency (ID) in pregnant Indian women is amongst the highest in the world. Untreated iron deficiency (ID) has significant adverse feto-maternal consequences. Plethora of investigations are available for diagnosis of IDA, each having specific advantages and disadvantages when used in the pregnancy setting. Therapy for ID includes dietary modification, oral iron supplementation, intravenous iron and blood transfusion. Newer parenteral iron preparations are safe and there is mounting evidence to suggest their use in frontline settings for pregnancy associated IDA in the second and third trimester. Through this review, we suggest an algorithm for diagnosis and treatment of IDA in pregnancy depending on the severity of anemia and period of gestation suited for widespread use in resource limited settings. Also, we recommend ways for increasing public awareness and tackling this health issue including the observance of "National Anemia Awareness and Treatment Day."
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Affiliation(s)
- Rimpy Tandon
- Department of Obstetrics and Gynaecology, Government Medical College and Hospital-32, Chandigarh, India
| | - Arihant Jain
- Department of Internal Medicine (Clinical Hematology Division), PGIMER, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine (Clinical Hematology Division), PGIMER, Chandigarh, India
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11
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Allen RP, Picchietti DL, Auerbach M, Cho YW, Connor JR, Earley CJ, Garcia-Borreguero D, Kotagal S, Manconi M, Ondo W, Ulfberg J, Winkelman JW. Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease in adults and children: an IRLSSG task force report. Sleep Med 2017; 41:27-44. [PMID: 29425576 DOI: 10.1016/j.sleep.2017.11.1126] [Citation(s) in RCA: 170] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 11/09/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Brain iron deficiency has been implicated in the pathophysiology of RLS, and current RLS treatment guidelines recommend iron treatment when peripheral iron levels are low. In order to assess the evidence on the oral and intravenous (IV) iron treatment of RLS and periodic limb movement disorder (PLMD) in adults and children, the International Restless Legs Syndrome Study Group (IRLSSG) formed a task force to review these studies and provide evidence-based and consensus guidelines for the iron treatment of RLS in adults, and RLS and PLMD in children. METHODS A literature search was performed to identify papers appearing in MEDLINE from its inception to July 2016. The following inclusion criteria were used: human research on the treatment of RLS or periodic limb movements (PLM) with iron, sample size of at least five, and published in English. Two task force members independently evaluated each paper and classified the quality of evidence provided. RESULTS A total of 299 papers were identified, of these 31 papers met the inclusion criteria. Four studies in adults were given a Class I rating (one for IV iron sucrose, and three for IV ferric carboxymaltose); only Class IV studies have evaluated iron treatment in children. Ferric carboxymaltose (1000 mg) is effective for treating moderate to severe RLS in those with serum ferritin <300 μg/l and could be used as first-line treatment for RLS in adults. Oral iron (65 mg elemental iron) is possibly effective for treating RLS in those with serum ferritin ≤75 μg/l. There is insufficient evidence to make conclusions on the efficacy of oral iron or IV iron in children. CONCLUSIONS Consensus recommendations based on clinical practice are presented, including when to use oral iron or IV iron, and recommendations on repeated iron treatments. New iron treatment algorithms, based on evidence and consensus opinion have been developed.
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Affiliation(s)
- Richard P Allen
- Department of Neurology, Johns Hopkins University, Hopkins Bayview Medical Center, Baltimore, MD, USA.
| | - Daniel L Picchietti
- University of Illinois College of Medicine at Urbana-Champaign and Carle Foundation Hospital, Urbana, IL, USA
| | - Michael Auerbach
- Department of Medicine, Georgetown University, Washington DC, USA
| | - Yong Won Cho
- Department of Neurology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - James R Connor
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey PA, USA
| | - Christopher J Earley
- Department of Neurology, Johns Hopkins University, Hopkins Bayview Medical Center, Baltimore, MD, USA
| | | | - Suresh Kotagal
- Department of Neurology and the Center for Sleep Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano, Lugano, Switzerland
| | - William Ondo
- Methodist Neurological Institute, Weill Cornell Medical School Houston, TX, USA
| | - Jan Ulfberg
- Sleep Disorders Department, Capio Health Center, Örebro, Sweden
| | - John W Winkelman
- Departments of Psychiatry and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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12
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Geyer J, Bogan R. Identification and treatment of augmentation in patients with restless legs syndrome: practical recommendations. Postgrad Med 2017; 129:667-675. [PMID: 28818004 DOI: 10.1080/00325481.2017.1360747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Restless legs syndrome (RLS) is a chronic disorder causing clinically significant discomfort to approximately 3% of adults. Although RLS was first identified centuries ago, our understanding of this disorder, its causes, and its treatments is still evolving. In particular, our knowledge of the potential negative effects of RLS treatments, including dopaminergic augmentation, continues to expand. Augmentation, which refers to a paradoxical treatment-related increase in RLS symptoms, has been associated with all three dopamine agonists approved for the treatment of RLS - rotigotine, pramipexole, and ropinirole. This review presents key information on prevention and treatment of dopaminergic augmentation from the recently published consensus-based guidelines issued by the International RLS Study Group task force in conjunction with the European RLS Study Group and the RLS Foundation for first-line treatment of RLS/Willis-Ekbom disease. If dopamine agonists are used to treat RLS, it is recommended that the dosage should be kept as low as possible without exceeding the maximum dose recommended for RLS treatment. As the frequency of augmentation with the rotigotine patch may only be slightly lower than that associated with pramipexole or ropinirole, medications that are effective and have little risk of augmentation, such as alpha-2-delta ligands, may be considered for initial RLS treatment. In addition, we present our clinical experience with treating patients with dopaminergic augmentation by highlighting 2 case studies and practical considerations when treating different patient populations. Applying current RLS augmentation diagnosis and treatment guidelines, as well as collecting detailed histories of worsening RLS symptoms, is critical for patient safety and effective management of RLS augmentation.
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Affiliation(s)
- James Geyer
- a Alabama Neurology & Sleep Medicine and Unosano, LLC , Tuscaloosa , AL , USA
| | - Richard Bogan
- b University of South Carolina School of Medicine and SleepMed, Inc. , Columbia , SC , USA
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13
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Trenkwalder C, Winkelmann J, Oertel W, Virgin G, Roubert B, Mezzacasa A. Ferric carboxymaltose in patients with restless legs syndrome and nonanemic iron deficiency: A randomized trial. Mov Disord 2017. [PMID: 28643901 PMCID: PMC5655783 DOI: 10.1002/mds.27040] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Compromised iron status is important in restless legs syndrome pathophysiology. We compared the efficacy and tolerability of ferric carboxymaltose (single intravenous dose) versus placebo for restless legs syndrome treatment in iron-deficient nonanemic patients. METHODS Patients with moderate to severe restless legs syndrome and serum ferritin < 75 μg/L (or serum ferritin 75-300 μg/L and transferrin saturation < 20%) were randomized to ferric carboxymaltose (1000 mg iron) or placebo. Mean change difference between ferric carboxymaltose and placebo in International Restless Legs Syndrome Severity Scale score from baseline to week 4 was the primary end point; week 12 was a secondary end point. RESULTS Ferric carboxymaltose treatment (n = 59) led to nonsignificant improvement over placebo (n = 51) in International Restless Legs Syndrome Severity Scale score at week 4 (difference [95% confidence interval], -2.5 [-5.93 to 1.02], P = 0.163), reaching significance by week 12 (-4.66 [-8.59 to -0.73], P = 0.021). CONCLUSIONS In patients who responded to treatment, ferric carboxymaltose may require more time to stabilize restless legs syndrome than previously assumed. © 2017 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Claudia Trenkwalder
- Department of Neurosurgery, University Medical Center, Göttingen, Germany.,Paracelsus-Elena Klinik, Kassel, Germany
| | - Juliane Winkelmann
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,Institut für Neurogenomik, Helmholtz Zentrum München, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Wolfgang Oertel
- Institut für Neurogenomik, Helmholtz Zentrum München, Munich, Germany.,Department of Neurology, Philipps-University Marburg, Marburg, Germany
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Abstract
Sleep disturbances and disorders are common during pregnancy, and they can be risk factors for a number of serious pregnancy-related sleep disorders. These include postpartum depression, pregnancy-induced hypertension, gestational diabetes, and intrauterine growth retardation. In addition, certain chronic sleep disorders, such as narcolepsy, are quite challenging to manage in the context of pregnancy and during lactation, particularly with medications that can be teratogenic. This review discusses 4 common sleep disorders and their impacts on pregnancy, and suggests ways to deal with these disorders that improves maternal and fetal outcomes safely. The review discusses diagnosis and treatment of obstructive sleep apnea, restless legs syndrome, insomnia, and narcolepsy in pregnancy.
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Affiliation(s)
- Margaret Kay-Stacey
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hrayr P. Attarian
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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15
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How I treat anemia in pregnancy: iron, cobalamin, and folate. Blood 2017; 129:940-949. [DOI: 10.1182/blood-2016-08-672246] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 12/21/2016] [Indexed: 01/28/2023] Open
Abstract
AbstractAnemia of pregnancy, an important risk factor for fetal and maternal morbidity, is considered a global health problem, affecting almost 50% of pregnant women. In this article, diagnosis and management of iron, cobalamin, and folate deficiencies, the most frequent causes of anemia in pregnancy, are discussed. Three clinical cases are considered. Iron deficiency is the most common cause. Laboratory tests defining iron deficiency, the recognition of developmental delays and cognitive abnormalities in iron-deficient neonates, and literature addressing the efficacy and safety of IV iron in pregnancy are reviewed. An algorithm is proposed to help clinicians diagnose and treat iron deficiency, recommending oral iron in the first trimester and IV iron later. Association of folate deficiency with neural tube defects and impact of fortification programs are discussed. With increased obesity and bariatric surgery rates, prevalence of cobalamin deficiency in pregnancy is rising. Low maternal cobalamin may be associated with fetal growth retardation, fetal insulin resistance, and excess adiposity. The importance of treating cobalamin deficiency in pregnancy is considered. A case of malarial anemia emphasizes the complex relationship between iron deficiency, iron treatment, and malaria infection in endemic areas; the heightened impact of combined etiologies on anemia severity is highlighted.
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Sleep Problems in Children with Attention Deficit/Hyperactivity Disorder: Current Status of Knowledge and Appropriate Management. Curr Psychiatry Rep 2016; 18:76. [PMID: 27357497 DOI: 10.1007/s11920-016-0711-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Attention deficit hyperactivity disorder (ADHD) affects approximately 5 % of children and adolescents, and sleep problems are common in these patients. There is growing evidence informing the significant importance of sleep problems in youth with ADHD. The sleep problems in children with ADHD include specific sleep disorders and sleep disturbances due to comorbid psychiatric disorders or ADHD medications. The specific sleep disorders of ADHD children include behaviorally based insomnia, sleep-disordered breathing, and restless legs syndrome/periodic limb movement disorder. Current practices on the management of sleep problems for ADHD children are based mostly on expert consensus, whereas more evidence-based literature can be found only recently. Assessment of the sleep conditions in ADHD children before initiation of pharmacotherapy is the currently recommended guideline, and good sleep hygiene can be considered as the first-line treatment option. In addition to modifying the dose regimens, formulation, or alternative stimulants when sleep problems are encountered in ADHD children, atomoxetine, once daily guanfacine extended release, and melatonin are potential choices for ADHD children with more severe sleep problems. In this review, we aimed to provide the most updated information, preferably based on meta-analyses, systemic review, and randomized controlled trials published in the latest 3 years, in order to be clinically useful for practitioners and clinicians.
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Rinaldi F, Galbiati A, Marelli S, Ferini Strambi L, Zucconi M. Treatment Options in Intractable Restless Legs Syndrome/Willis-Ekbom Disease (RLS/WED). Curr Treat Options Neurol 2016; 18:7. [PMID: 26874840 DOI: 10.1007/s11940-015-0390-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OPINION STATEMENT Restless Legs Syndrome/Willis-Ekbom Disease (RLS/WED) is a common condition characterized by an irresistible urge to move the legs, concomitant with an unpleasant sensation in the lower limbs, which is typically relieved by movement. Symptoms occur predominantly at rest and prevail in the afternoon or evening. Treatment of patients with RLS/WED is indicated for those patients who suffer from clinically relevant symptoms. The management of mild forms of RLS/WED is mainly based on dopamine agonists (DA) therapy (including pramipexole and ropinirole) and α-2-δ calcium-channel ligand. Nevertheless, with passing of time, symptoms tend to become more severe and the patient can eventually develop pharmacoresistance. Furthermore, long-term treatment with dopaminergic agents may be complicated by the development of augmentation, which is defined by an increase in the severity and frequency of RLS/WED symptoms despite adequate treatment. Here, we discuss which are the best therapeutic options when RLS/WED becomes intractable, with a focus on advantages and side effects of the available medications. Prevention strategies include managing lifestyle changes and a good sleep hygiene. Different drug options are available. Switching to longer-acting dopaminergic agents may be a possibility if the patient is well-tolerating DA treatment. An association with α-2-δ calcium-channel ligand is another first-line approach. In refractory RLS/WED, opioids such as oxycodone-naloxone have demonstrated good efficacy. Other pharmacological approaches include IV iron, benzodiazepines such as clonazepam, and antiepileptic drugs, with different level of evidence of efficacy. Therefore, the final decision regarding the agent to use in treating severe RLS/WED symptoms should be tailored to the patient, taking into account the symptomatology, comorbidities, the availability of treatment and the history of the disease.
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Affiliation(s)
- Fabrizio Rinaldi
- Department of Clinical Neurosciences, Sleep Disorders Centre, San Raffaele Scientific Institute, Milan, Italy.,Neurology Clinic, Spedali Civili di Brescia Hospital, University of Brescia, Brescia, Italy
| | - Andrea Galbiati
- Department of Clinical Neurosciences, Sleep Disorders Centre, San Raffaele Scientific Institute, Milan, Italy.,Faculty of Psychology, Vita-Salute San Raffaele University, Milan, Italy
| | - Sara Marelli
- Department of Clinical Neurosciences, Sleep Disorders Centre, San Raffaele Scientific Institute, Milan, Italy.,Faculty of Psychology, Vita-Salute San Raffaele University, Milan, Italy
| | - Luigi Ferini Strambi
- Department of Clinical Neurosciences, Sleep Disorders Centre, San Raffaele Scientific Institute, Milan, Italy.,Faculty of Psychology, Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Zucconi
- Department of Clinical Neurosciences, Sleep Disorders Centre, San Raffaele Scientific Institute, Milan, Italy.
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