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Heidbreder A, Trenkwalder C, Bachmann CG, Bartl M, Fulda S, Habersack L, Maihöfner C, Mathis J, Muntean L, Schneider B, Stefani A, Paulus J, Young P. Restless Legs Syndrom. SOMNOLOGIE 2023. [DOI: 10.1007/s11818-023-00399-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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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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Zeising M, Thiedemann C, Pollmächer T. [Sleep medicine in psychiatry and psychotherapy]. DER NERVENARZT 2022; 93:313-324. [PMID: 35201393 DOI: 10.1007/s00115-022-01262-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
Abstract
Sleep medicine is a cross-disciplinary subject with high relevance for psychiatry and psychotherapy. The three most common sleep disorders (insomnia, sleep apnea syndrome and restless legs syndrome) are presented here with practical relevance. Cognitive behavioral therapy is the treatment of choice for insomnia, whereas symptomatic drug treatment (especially with GABA receptor agonists) should be used with caution. Sleep-related breathing disorders have a high prevalence of around 24% among psychiatric inpatients in Germany. Typical symptoms of obstructive sleep apnea syndrome should lead to a staged diagnostic process and, if necessary, cardiorespiratory polysomnography. It is not unusual for restless legs syndrome to be caused by psychopharmacological treatment. The primary form was usually treated with dopamine or dopamine agonists but due to the risk of augmentation, alternatives should be considered more often.
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Affiliation(s)
- Marcel Zeising
- Zentrum für psychische Gesundheit, Klinikum Ingolstadt, Krumenauerstr. 25, 85049, Ingolstadt, Deutschland.
| | - Christian Thiedemann
- Universitätsklinik für Neurologie, Landeskrankenhaus-Universitätskliniken Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - Thomas Pollmächer
- Zentrum für psychische Gesundheit, Klinikum Ingolstadt, Krumenauerstr. 25, 85049, Ingolstadt, Deutschland
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Abstract
Restless Legs Syndrome (RLS) is a sensorimotor disorder that severely affects sleep. It is characterized by an urge to move the legs that is often accompanied by periodic limb movements during sleep (PLMS). RLS has a high prevalence in the population and is usually a life-long condition. While its origins remain unclear, RLS is initially highly responsive to treatment with dopaminergics that target the D3 receptor. However, over time patients often develop a gradual tolerance that can lead to the emergence of adverse effects and the augmentation of the symptoms. While the basal ganglia and the striatum control leg movements, the lumbar spinal cord is the gateway for the sensory processing of the symptoms and critical for the associated leg movements. D3 receptors are highly expressed in nucleus accumbens (NAc) of the striatum and the sensory-processing areas of the spinal dorsal horn. In contrast, D1 receptors are strongly expressed throughout the entire striatum and in the ventral horn of the spinal cord. Long-term treatment with D3 receptor full agonists is associated with an upregulation of the D1 receptor subtype, and D3 and D1 receptors can form functional heteromers, in which the D3R controls the D1R function. It is conceivable that the switch from beneficial treatment to augmentation observed in RLS patients after prolonged D3R agonist exposure may be the result of unmasked D1-like receptor actions.
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Affiliation(s)
- Stefan Clemens
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
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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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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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D3 and D1 receptors: The Yin and Yang in the treatment of restless legs syndrome with dopaminergics. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2019; 84:79-100. [PMID: 31229178 DOI: 10.1016/bs.apha.2019.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Dopaminergic treatments targeting the D3 receptor subtype to reduce the symptoms of RLS show substantial initial clinical benefits but fail to maintain their efficacy over time. Sensorimotor circuits in the spinal cord are the gateway for the sensory processing of the symptoms and critical for the associated leg movements that relieve the symptoms and the periodic limb movements that often develop during sleep. There is a high preponderance of the inhibitory D3 receptor in the sensory-processing areas of the spinal cord (dorsal horn), whereas the motor areas in the ventral horn more strongly express the excitatory D1 receptor subtype. D3 and D1 receptors can form functional heteromeric ensembles that influence each other. In the spinal cord, long-term treatment with D3 receptor agonists is associated with the upregulation of the D1 receptor subtype and block of D1 receptor function at this stage can restore the D3 receptor effect. Alternate scenarios for a role of dopamine involve a role for the D5 receptor in regulating motor excitability and for the D4 receptor subtype in controlling D3-like effects. A model emerges that proposes that the behavioral changes in RLS, while responsive to D3 receptor agonists, may be ultimately be the result of unmasked increased D1-like receptor activities.
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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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Comorbidities, treatment, and pathophysiology in restless legs syndrome. Lancet Neurol 2018; 17:994-1005. [PMID: 30244828 DOI: 10.1016/s1474-4422(18)30311-9] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/05/2018] [Accepted: 08/08/2018] [Indexed: 12/11/2022]
Abstract
Restless legs syndrome, also known as Willis-Ekbom disease, is a common neurological condition whose manifestation is affected by complex environmental and genetic interactions. Restless legs syndrome can occur on its own, mostly at a young age, or with comorbidities such as cardiovascular disease, diabetes, and arterial hypertension, making it a difficult condition to properly diagnose. However, the concept of restless legs syndrome as being two entities, primary or secondary to another condition, has been challenged with genetic data providing further insight into the pathophysiology of the condition. Although dopaminergic treatment was formerly the first-line therapy, prolonged use can result in a serious worsening of symptoms known as augmentation. Clinical studies on pregabalin, gabapentin enacarbil, oxycodone-naloxone, and iron preparations have provided new treatment options, but most patients still report inadequate long-term management of symptoms. Studies of the hypoxic pathway activation and iron deficiency have provided valuable information about the pathophysiology of restless legs syndrome that should now be translated into new, more effective treatments for restless legs syndrome.
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Meneely S, Dinkins ML, Kassai M, Lyu S, Liu Y, Lin CT, Brewer K, Li Y, Clemens S. Differential Dopamine D1 and D3 Receptor Modulation and Expression in the Spinal Cord of Two Mouse Models of Restless Legs Syndrome. Front Behav Neurosci 2018; 12:199. [PMID: 30233336 PMCID: PMC6131574 DOI: 10.3389/fnbeh.2018.00199] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 08/13/2018] [Indexed: 12/22/2022] Open
Abstract
Restless Legs Syndrome (RLS) is often and successfully treated with dopamine receptor agonists that target the inhibitory D3 receptor subtype, however there is no clinical evidence of a D3 receptor dysfunction in RLS patients. In contrast, genome-wide association studies in RLS patients have established that a mutation of the MEIS1 gene is associated with an increased risk in developing RLS, but the effect of MEIS1 dysfunction on sensorimotor function remain unknown. Mouse models for a dysfunctional D3 receptor (D3KO) and Meis1 (Meis1KO) were developed independently, and each animal expresses some features associated with RLS in the clinic, but they have not been compared in their responsiveness to treatment options used in the clinic. We here confirm that D3KO and Meis1KO animals show increased locomotor activities, but that only D3KO show an increased sensory excitability to thermal stimuli. Next we compared the effects of dopaminergics and opioids in both animal models, and we assessed D1 and D3 dopamine receptor expression in the spinal cord, the gateway for sensorimotor processing. We found that Meis1KO share most of the tested behavioral properties with their wild type (WT) controls, including the modulation of the thermal pain withdrawal reflex by morphine, L-DOPA and D3 receptor (D3R) agonists and antagonists. However, Meis1KO and D3KO were behaviorally more similar to each other than to WT when tested with D1 receptor (D1R) agonists and antagonists. Subsequent Western blot analyses of D1R and D3R protein expression in the spinal cord revealed a significant increase in D1R but not D3R expression in Meis1KO and D3KO over WT controls. As the D3R is mostly present in the dorsal spinal cord where it has been shown to modulate sensory pathways, while activation of the D1Rs can activate motoneurons in the ventral spinal cord, we speculate that D3KO and Meis1KO represent two complementary animal models for RLS, in which the mechanisms of sensory (D3R-mediated) and motor (D1R-mediated) dysfunctions can be differentially explored.
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Affiliation(s)
- Samantha Meneely
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Mai-Lynne Dinkins
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Miki Kassai
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Shangru Lyu
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Yuning Liu
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Chien-Te Lin
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
- East Carolina Diabetes and Obesity Institute, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Kori Brewer
- Department of Emergency Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - Yuqing Li
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, United States
- Wuxi Medical School, Jiangnan University, Wuxi, China
| | - Stefan Clemens
- Department of Physiology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
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Long-term treatment with dopamine D3 receptor agonists induces a behavioral switch that can be rescued by blocking the dopamine D1 receptor. Sleep Med 2017; 40:47-52. [DOI: 10.1016/j.sleep.2017.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/29/2017] [Accepted: 10/04/2017] [Indexed: 11/23/2022]
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Wijemanne S, Ondo W. Restless Legs Syndrome: clinical features, diagnosis and a practical approach to management. Pract Neurol 2017; 17:444-452. [PMID: 29097554 DOI: 10.1136/practneurol-2017-001762] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2017] [Indexed: 11/04/2022]
Abstract
Restless legs syndrome (RLS) is a chronic neurological disorder that interferes with rest and sleep. It has a wide spectrum of symptom severity, and treatment is started when symptoms become bothersome. Dopamine agonists and calcium channel apha-2-delta antagonists (gabapentin, gabapentin enacarbil and pregabalin) are first-line treatments; calcium channel alpha-2-deltas are preferred over dopamine agonists because they give less augmentation, a condition with symptom onset earlier in the day and intensification of RLS symptoms. Dopamine agonists can still be used as first-line therapy, but the dose should be kept as low as possible. Iron supplements are started when the serum ferritin concentration is ≤75 µg/L, or if the transferrin saturation is less than 20%. For severe or resistant RLS, a combined treatment approach can be effective. Augmentation can be very challenging to treat and lacks evidenced-based guidelines.
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Affiliation(s)
- Subhashie Wijemanne
- Department of Neurology, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - William Ondo
- Department of Neurology, Weill Cornell Medical School, Methodist Neurological Institute, Houston, Texas, USA
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Garcia-Borreguero D. Restless legs syndrome (Willis-Ekbom disease): an urgent need for better treatments. Sleep Med 2017; 30:266-267. [PMID: 28041721 DOI: 10.1016/j.sleep.2015.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 12/14/2015] [Indexed: 11/30/2022]
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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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