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Al-Kassmy J, Alsalmi M, Kang W, Huot P. Anticonvulsant Agents for Treatment of Restless Legs Syndrome: A Case Report With Lamotrigine and a Review of the Literature. Neurologist 2024; 29:173-178. [PMID: 38250816 DOI: 10.1097/nrl.0000000000000552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
INTRODUCTION Restless Legs Syndrome (RLS) is a neurological disorder primarily treated with pregabalin and gabapentin, followed by dopamine agonists later in the process due to the risk of augmenting RLS symptoms. In addition, clinical reports have disclosed varying degrees of success employing other agents in patients unresponsive to traditional agents. Here, we present a patient who had success in the reduction of RLS symptoms with lamotrigine, a broad-spectrum anticonvulsant. Previously, lamotrigine had been used in 2 trials with successful treatment of RLS. CASE REPORT We present a 58-year-old right-handed lady with long-standing history of smoking, hypertension, dyslipidaemia, prediabetes, gastro-esophageal reflux disease, asthma, strabismus, uterine cancer, severe and debilitating course of RLS accompanied by unexplained deterioration. The patient initially demonstrated abnormal sensation in all her limbs, which worsened with radiotherapy treatment, and was eventually diagnosed with RLS based on the diagnostic criteria. Subsequent examinations were unremarkable and revealed no further explanation for the deterioration of the RLS symptoms. While the complexity of the patient's medical history had exposed her to a variety of medications, she reported that only lamotrigine, in addition to her original regimen of methadone and pramipexole, offered significant symptomatic relief. It must be noted that no adverse side effects, including impulse-control disorder, were reported by the patient. CONCLUSIONS We present a case of a woman whose deteriorating symptoms of RLS were successfully alleviated by the administration of lamotrigine. This is only the third case in the literature to have successfully utilized lamotrigine as a treatment option for RLS.
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Affiliation(s)
- Jawad Al-Kassmy
- Royal College of Surgeons in Ireland, School of Medicine, Dublin, Ireland
| | - Mohammed Alsalmi
- Department of Neurosciences, Division of Neurology, Movement Disorder Clinic, McGill University Health Centre
| | - Woojin Kang
- Neurodegenerative Disease Group, Montreal Neurological Institute-Hospital (The Neuro)
| | - Philippe Huot
- Department of Neurosciences, Division of Neurology, Movement Disorder Clinic, McGill University Health Centre
- Neurodegenerative Disease Group, Montreal Neurological Institute-Hospital (The Neuro)
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada
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Pellitteri G, Versace S, Merlino G, Nilo A, Gigli GL, Valente M. A comprehensive update on the ADMET considerations for α2δ calcium channel ligand medications for treating restless legs syndrome. Expert Opin Drug Metab Toxicol 2024; 20:133-142. [PMID: 38482850 DOI: 10.1080/17425255.2024.2329738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/08/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Restless legs syndrome/Willis-Ekbom disease (RLS/WED) is a sleep-related sensory-motor disorder associated with poor sleep quality and impaired daily functioning. In patients affected by chronic RLS/WED, a pharmacological therapy is recommended. International guidelines suggest to start the treatment with a α2δ calcium channel ligand in most cases, unless contraindicated. AREAS COVERED The present review is based on an extensive Internet and PubMed search from 1986 to 2024. Our purpose is to describe the absorption, distribution, metabolism, and toxicology (ADMET) of the α2δ ligands, with common consideration for the therapeutic class, specificities of different compounds, efficacy, and safety in relation to other treatment options. EXPERT OPINION α2δ ligands are quite similar in their ADMET profiles, sharing most of the pharmacokinetics and potential adverse effects. However, we highlight the linear kinetic of gabapentin enacarbil and pregabalin, differently from gabapentin. α2δ ligands are safe and effective for the treatment of RLS/WED. Additional benefits can be obtained in comorbid insomnia, chronic pain syndromes, history of impulse control disorder, and comorbid anxiety. The use of α2δ ligands is associated with poor risk of augmentation. We still need new long-term safe and effective treatments, which could be developed along with our knowledge of RLS/WED pathophysiology.
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Affiliation(s)
- Gaia Pellitteri
- Clinical Neurology Unit, Udine University Hospital, Udine, Italy
| | - Salvatore Versace
- Clinical Neurology Unit, Udine University Hospital, Udine, Italy
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology Unit, Udine University Hospital, Udine, Italy
| | - Annacarmen Nilo
- Clinical Neurology Unit, Udine University Hospital, Udine, Italy
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Gian Luigi Gigli
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, Udine University Hospital, Udine, Italy
- Department of Medicine (DMED), University of Udine, Udine, Italy
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Walters AS, Li Y, Koo BB, Ondo WG, Weinstock LB, Champion D, Afrin LB, Karroum EG, Bagai K, Spruyt K. Review of the role of the endogenous opioid and melanocortin systems in the restless legs syndrome. Brain 2024; 147:26-38. [PMID: 37633259 PMCID: PMC10796165 DOI: 10.1093/brain/awad283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/23/2023] [Accepted: 08/01/2023] [Indexed: 08/28/2023] Open
Abstract
Restless legs syndrome (RLS) is responsive to opioid, dopaminergic and iron-based treatments. Receptor blocker studies in RLS patients suggest that the therapeutic efficacy of opioids is specific to the opioid receptor and mediated indirectly through the dopaminergic system. An RLS autopsy study reveals decreases in endogenous opioids, β-endorphin and perhaps Met-enkephalin in the thalamus of RLS patients. A total opioid receptor knock-out (mu, delta and kappa) and a mu-opioid receptor knock-out mouse model of RLS show circadian motor changes akin to RLS and, although both models show sensory changes, the mu-opioid receptor knock mouse shows circadian sensory changes closest to those seen in idiopathic RLS. Both models show changes in striatal dopamine, anaemia and low serum iron. However, only in the total receptor knock-out mouse do we see the decreases in serum ferritin that are normally found in RLS. There are also decreases in serum iron when wild-type mice are administered a mu-opioid receptor blocker. In addition, the mu-opioid receptor knock-out mouse also shows increases in striatal zinc paralleling similar changes in RLS. Adrenocorticotropic hormone and α-melanocyte stimulating hormone are derived from pro-opiomelanocortin as is β-endorphin. However, they cause RLS-like symptoms and periodic limb movements when injected intraventricularly into rats. These results collectively suggest that an endogenous opioid deficiency is pathogenetic to RLS and that an altered melanocortin system may be causal to RLS as well.
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Affiliation(s)
- Arthur S Walters
- Sleep Division, Department of Neurology, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Yuqing Li
- Norman Fixel Institute for Neurological Diseases, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Brian B Koo
- Sleep Medicine Laboratory, VA Connecticut Health Care System, West Haven, CT 06516, USA
- Yale Center for Restless Legs Syndrome, Yale School of Medicine, New Haven, CT 06520, USA
| | - William G Ondo
- Department of Neurology, Methodist Hospital, Weill Cornell Medical School, Houston, TX 77030, USA
| | - Leonard B Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St.Louis, MO 63130, USA
| | - David Champion
- Sydney Children's Hospital, Department of Pain Medicine, Randwick, NSW 2031, Australia
| | - Lawrence B Afrin
- Hematology/Oncology, AIM Center for Personalized Medicine, Purchase, NY 10577, USA
| | - Elias G Karroum
- Department of Neurology and Rehabilitation Medicine, The George Washington University School of Medicine and Health Sciences, George Washington University, Washington, D.C. 20052, USA
| | - Kanika Bagai
- Sleep Division, Department of Neurology, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Karen Spruyt
- Université Paris Cité, NeuroDiderot Inserm, Paris 75019, France
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Hackethal S, Maino P, Koetsier E, Manconi M. Spinal cord stimulation in severe pharmacoresistant restless legs syndrome-two case reports. Front Neurol 2023; 14:1219881. [PMID: 38099065 PMCID: PMC10720037 DOI: 10.3389/fneur.2023.1219881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/18/2023] [Indexed: 12/17/2023] Open
Abstract
Restless legs syndrome is a prevalent, sleep-related sensorimotor disorder with relevant impact on the patients' quality of life. For patients suffering from severe, pharmacoresistant restless legs syndrome, few therapeutic options remain to alleviate symptoms. In this case series, two patients with severe, pharmacoresistant restless legs syndrome were treated with epidural spinal cord stimulation and repeatedly assessed with polysomnography, including sleep structure and periodic limb movements as objective biomarkers not subject to placebo effects, during a 6-month follow-up period. One of the patients experienced excellent short- and long-term efficacy on subjective symptom severity (International RLS Study group rating scale 1 vs. 34 points at 3 months) and objective sleep parameters such as sleep architecture and periodic limb movements during sleep, while the second patient only reported short-term benefits from spinal cord stimulation. Ultimately, both patients opted for removal of the device for inefficacy. Based on the complex pathophysiology of restless legs syndrome and presumed mechanism of action of spinal cord stimulation in chronic pain disorders, we provide a detailed hypothesis on the possible modulating effect of spinal cord stimulation on the key symptoms of restless legs syndrome. Apart from describing a new therapeutic option for pharmacoresistant restless legs syndrome, our findings might also provide further insights into the pathophysiology of the syndrome.
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Affiliation(s)
- Sandra Hackethal
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Paolo Maino
- Pain Management Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Eva Koetsier
- Pain Management Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Mauro Manconi
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
- Department of Neurology, University Hospital, Inselspital, Bern, Switzerland
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Alaçam Köksal S, Boncuk Ulaş S, Acar BA, Acar T, Güzey Aras Y, Köroğlu M. Evaluation of the relationship between idiopathic restless legs syndrome and serum hepcidin levels. Brain Behav 2023; 13:e3259. [PMID: 37726920 PMCID: PMC10636386 DOI: 10.1002/brb3.3259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION The relationship between restless legs syndrome (RLS) and iron deficiency is a well-known topic. However, the etiology of the disease has not been determined. As the central iron deficiency is the most critical biological abnormality for RLS, we planned a study examining the relationship between RLS and hepcidin, which is the only regulatory hormone of iron metabolism known so far. METHODS International Restless Legs Syndrome Study Group diagnostic criteria (2014) were taken as a basis. A total of 40 RLS patients and 40 healthy controls were included in the study. To avoid the potential variables that might cause secondary RLS, all the participants were asked to provide hemogram, ferritin, iron, thyroid function tests, and sedimentation analysis. The hepcidin levels were measured with a Human Hepcidin (Hepc 25) ELISA kit (MyBioSource). RESULTS The statistically significant results of our analysis show that the red blood cell count, the neutrophil count, the percentage of lymphocytes and neutrophils, and, more distinctively, hepcidin levels were higher in RLS patients in comparison with the control group. CONCLUSION In this study, no differences were found in iron and ferritin values. High levels of hepcidin, the main regulator of iron metabolism, in those with primary RLS support the possibility that hepcidin may play a role in the pathogenesis of RLS. We think that larger studies on this subject can give clearer ideas.
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Affiliation(s)
| | | | | | - Türkan Acar
- Department of Neurology, Faculty of MedicineSakarya UniversitySerdivanSakaryaTurkey
| | - Yeşim Güzey Aras
- Department of Neurology, Faculty of MedicineSakarya UniversitySerdivanSakaryaTurkey
| | - Mehmet Köroğlu
- Department of Microbiology, Faculty of MedicineSakarya UniversitySerdivanSakaryaTurkey
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Chenini S, Barateau L, Dauvilliers Y. Restless legs syndrome: From clinic to personalized medicine. Rev Neurol (Paris) 2023; 179:703-714. [PMID: 37689536 DOI: 10.1016/j.neurol.2023.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2023]
Abstract
Restless legs syndrome (RLS) is a common neurological sensorimotor disorder that impairs sleep, mood and quality of life. RLS is defined by an urge to move the legs at rest that increases in the evening and at night, and is frequently associated with metabolic and cardiovascular diseases. Symptoms frequency, age at RLS onset, severity, familial history and consequences of RLS vary widely between patients. A genetic susceptibility, iron deficiency, dopamine deregulation, and possible hypo-adenosinergic state may play a role in the pathophysiology of RLS. Polysomnographic recordings found often periodic leg movements during sleep and wakefulness in patients with RLS. RLS can be classified as primary or comorbid with major diseases: iron deficiency, renal, neurological, rheumatological and lung diseases. First-line treatments are low-dose dopamine agonists, and alpha-2-delta ligands depending on the clinical context, and second/third line opiates for pharmacoresistant forms of RLS. Augmentation syndrome is a serious complication of dopamine agonists and should be prevented by using the recommended low dose. Despite an increase in knowledge, RLS is still underdiagnosed, poorly recognized, resulting in substantial individual health burden and socioeconomic coast, and education is urgently needed to increase awareness of this disabling disorder.
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Affiliation(s)
- S Chenini
- National Reference Centre for Orphan Diseases Narcolepsy and Rare Hypersomnias, Sleep Unit, Department of Neurology, CHU Montpellier, University of Montpellier, Montpellier, France; Institute for Neurosciences of Montpellier (INM), University of Montpellier, INSERM, Montpellier, France.
| | - L Barateau
- National Reference Centre for Orphan Diseases Narcolepsy and Rare Hypersomnias, Sleep Unit, Department of Neurology, CHU Montpellier, University of Montpellier, Montpellier, France; Institute for Neurosciences of Montpellier (INM), University of Montpellier, INSERM, Montpellier, France
| | - Y Dauvilliers
- National Reference Centre for Orphan Diseases Narcolepsy and Rare Hypersomnias, Sleep Unit, Department of Neurology, CHU Montpellier, University of Montpellier, Montpellier, France; Institute for Neurosciences of Montpellier (INM), University of Montpellier, INSERM, Montpellier, France.
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Zeng P, Wang T, Zhang L, Guo F. Exploring the causes of augmentation in restless legs syndrome. Front Neurol 2023; 14:1160112. [PMID: 37840917 PMCID: PMC10571710 DOI: 10.3389/fneur.2023.1160112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Long-term drug treatment for Restless Legs Syndrome (RLS) patients can frequently result in augmentation, which is the deterioration of symptoms with an increased drug dose. The cause of augmentation, especially derived from dopamine therapy, remains elusive. Here, we review recent research and clinical progress on the possible mechanism underlying RLS augmentation. Dysfunction of the dopamine system highly possibly plays a role in the development of RLS augmentation, as dopamine agonists improve desensitization of dopamine receptors, disturb receptor interactions within or outside the dopamine receptor family, and interfere with the natural regulation of dopamine synthesis and release in the neural system. Iron deficiency is also indicated to contribute to RLS augmentation, as low iron levels can affect the function of the dopamine system. Furthermore, genetic risk factors, such as variations in the BTBD9 and MEIS1 genes, have been linked to an increased risk of RLS initiation and augmentation. Additionally, circadian rhythm, which controls the sleep-wake cycle, may also contribute to the worsening of RLS symptoms and the development of augmentation. Recently, Vitamin D deficiency has been suggested to be involved in RLS augmentation. Based on these findings, we propose that the progressive reduction of selective receptors, influenced by various pathological factors, reverses the overcompensation of the dopamine intensity promoted by short-term, low-dose dopaminergic therapy in the development of augmentation. More research is needed to uncover a deeper understanding of the mechanisms underlying the RLS symptom and to develop effective RLS augmentation treatments.
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Affiliation(s)
- Pengyu Zeng
- Department of Neurobiology, Department of Neurology of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Science Center for Brain Research and Brain-Machine Integration, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China
| | - Tiantian Wang
- Department of Pharmacy, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Center for Sleep Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lisan Zhang
- Department of Neurobiology, Department of Neurology of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Center for Sleep Medicine, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fang Guo
- Department of Neurobiology, Department of Neurology of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- NHC and CAMS Key Laboratory of Medical Neurobiology, MOE Frontier Science Center for Brain Research and Brain-Machine Integration, School of Brain Science and Brain Medicine, Zhejiang University, Hangzhou, China
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Pamlényi K, Regdon G, Jójárt-Laczkovich O, Nemes D, Bácskay I, Kristó K. Formulation and characterization of pramipexole containing buccal films for using in Parkinson's disease. Eur J Pharm Sci 2023:106491. [PMID: 37301240 DOI: 10.1016/j.ejps.2023.106491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 05/15/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Abstract
Parkinson's disease (PD) is neurodegenerative chronic illness which affects primarily the elderly over 45 years of age. The symptoms can be various, both non-motor and motor symptoms can appear. The biggest problem in the treatment of the disease is the difficulty in swallowing for the patients. However, buccal patches can solve this problem because the patients do not have to swallow the dosage form, and during application, the API can absorb from the area of the buccal mucosa quickly without causing a foreign body sensation. In our present study, we focused on the development of buccal polymer films with pramipexole dihydrochloride (PR). Films with different compositions were formulated and their mechanical properties and chemical interactions were investigated. The biocompatibility of the film compositions was examined on the TR146 buccal cell line. The permeation of PR was also monitored across the TR146 human cell line. It can be stated that the plasticizer can enhance the thickness and the breaking hardness of the films, while not decreasing their mucoadhesivity significantly. All formulations proved to have cell viability higher than 87%. Finally, we found the best composition (3% SA+1% GLY-PR-Sample1) which can be applied on the buccal mucosa in the treatment of PD.
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Affiliation(s)
- Krisztián Pamlényi
- Institute of Pharmaceutical Technology and Regulatory Affairs, University of Szeged, Eötvös u. 6., H-6720 Szeged, Hungary
| | - Géza Regdon
- Institute of Pharmaceutical Technology and Regulatory Affairs, University of Szeged, Eötvös u. 6., H-6720 Szeged, Hungary.
| | - Orsolya Jójárt-Laczkovich
- Institute of Pharmaceutical Technology and Regulatory Affairs, University of Szeged, Eötvös u. 6., H-6720 Szeged, Hungary
| | - Dániel Nemes
- Department of Pharmaceutical Technology, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary
| | - Ildikó Bácskay
- Department of Pharmaceutical Technology, University of Debrecen, Nagyerdei krt. 98., H-4032 Debrecen, Hungary
| | - Katalin Kristó
- Institute of Pharmaceutical Technology and Regulatory Affairs, University of Szeged, Eötvös u. 6., H-6720 Szeged, Hungary
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Cederberg KLJ, Silvestri R, Walters AS. Vitamin D and Restless Legs Syndrome: A Review of Current Literature. Tremor Other Hyperkinet Mov (N Y) 2023; 13:12. [PMID: 37034443 PMCID: PMC10077981 DOI: 10.5334/tohm.741] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/16/2023] [Indexed: 04/08/2023] Open
Abstract
This review presents a detailed summary of the current literature regarding RLS and vitamin D deficiency. To our knowledge it is the first review of its kind. We review the prevalence of vitamin D deficiency in RLS as well as the evidence for the use of vitamin D supplementation in RLS management. We further examine the literature for proteomic and genetic evidence of a role for vitamin D in the pathogenesis of RLS. An alteration in vitamin D binding protein in RLS is one of the most consistent findings in the proteomic studies. Furthermore, we examine the interaction of vitamin D with calcium, phosphorus, and parathyroid hormone and the possible role of these connections in RLS. We also explore the possible nexus between RLS and vitamin D in renal disease, cardiovascular and cerebrovascular disease as well as inflammation. In addition, we review the potential interaction between vitamin D and RLS with iron, dopamine and other neurotransmitter systems including the endogenous opiate, serotoninergic, glutamatergic and adenosinergic systems. We also explore the role of vitamin D in RLS Augmentation (i.e., the paradoxical worsening of RLS symptoms when dopaminergic agents are used as a therapy for RLS). Although the literature is not entirely consistent in affirming vitamin D deficiency in RLS or the amelioration of RLS symptoms with vitamin D therapy, the collective studies overall indicate that vitamin D deficiency is common enough in RLS patients to suggest that RLS patients should have their vitamin D levels checked and any deficiency corrected as a standard of care. Highlights Patients with Restless Legs Syndrome (RLS) may be deficient in vitamin D and therapy with vitamin D may ameliorate RLS. We present the first review dedicated solely to evaluating the relationship between RLS and vitamin D and present a case for the role of vitamin D in RLS pathogenesis.
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Affiliation(s)
- Katie L. J. Cederberg
- Department of Psychiatry & Behavioral Sciences, Stanford University, 3165 Porter Drive Palo Alto, CA, USA
| | - Rosalia Silvestri
- Department of Clinical and Experimental Medicine, Sleep Medicine Center, University of Messina, Azienda Ospedaliera Universitaria “Gaetano Martino”, Messina, Italy
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Lauretani F, Testa C, Salvi M, Zucchini I, Giallauria F, Maggio M. Clinical Evaluation of Sleep Disorders in Parkinson’s Disease. Brain Sci 2023; 13:brainsci13040609. [PMID: 37190574 DOI: 10.3390/brainsci13040609] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/07/2023] Open
Abstract
The paradigm of the framing of Parkinson’s disease (PD) has undergone significant revision in recent years, making this neurodegenerative disease a multi-behavioral disorder rather than a purely motor disease. PD affects not only the “classic” substantia nigra at the subthalamic nuclei level but also the nerve nuclei, which are responsible for sleep regulation. Sleep disturbances are the clinical manifestations of Parkinson’s disease that most negatively affect the quality of life of patients and their caregivers. First-choice treatments for Parkinson’s disease determine amazing effects on improving motor functions. However, it is still little known whether they can affect the quantity and quality of sleep in these patients. In this perspective article, we will analyze the treatments available for this specific clinical setting, hypothesizing a therapeutic approach in relation to neurodegenerative disease state.
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Affiliation(s)
- Fulvio Lauretani
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Clinic Geriatric Unit and Cognitive and Motor Center, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy
| | - Crescenzo Testa
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Marco Salvi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Irene Zucchini
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Francesco Giallauria
- Department of Translational Medical Sciences, “Federico II” University of Naples, Via S. Pansini 5, 80131 Naples, Italy
| | - Marcello Maggio
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Clinic Geriatric Unit and Cognitive and Motor Center, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy
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Riccardi S, Ferri R, Garbazza C, Miano S, Manconi M. Pharmacological responsiveness of periodic limb movements in patients with restless legs syndrome: a systematic review and meta-analysis. J Clin Sleep Med 2023; 19:811-822. [PMID: 36692194 PMCID: PMC10071388 DOI: 10.5664/jcsm.10440] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/06/2022] [Accepted: 12/06/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVES Periodic limb movements during sleep (PLMS) are a frequent finding in restless legs syndrome, but their impact on sleep is still debated, as well the indication for treatment. We systematically reviewed the available literature to describe which drug categories are effective in suppressing PLMS, assessing their efficacy through a meta-analysis, when this was possible. METHODS The review protocol was preregistered on PROSPERO (CRD42021175848), and the systematic search was conducted on and EMBASE (last searched on March 2020). We included original human studies, which assessed PLMS modification on drug treatment with a full-night polysomnography, through surface electrodes on each tibialis anterior muscle. When at least 4 studies were available on the same drug or drug category, we performed a random-effect model meta-analysis. RESULTS Dopamine agonists like pramipexole and ropinirole resulted the most effective, followed by l-dopa and other dopamine agonists. Alpha2delta ligands are moderately effective as well opioids, despite available data on these drugs are much more limited than those on dopaminergic agents. Valproate and carbamazepine did not show a significant effect on PLMS. Clonazepam showed contradictory results. Perampanel and dypiridamole showed promising but still insufficient data. The same applies to iron supplementation. CONCLUSIONS Dopaminergic agents are the most powerful suppressors of PLMS. However, most therapeutic trials in restless legs syndrome do not report objective polysomnographic findings, there is a lack of uniformity in presenting results on PLMS. Longitudinal polysomnographic interventional studies, using well-defined and unanimous scoring criteria and endpoints on PLMS are needed. CITATION Riccardi S, Ferri R, Garbazza C, Miano S, Manconi M. Pharmacological responsiveness of periodic limb movements in patients with restless legs syndrome: a systematic review and meta-analysis. J Clin Sleep Med. 2023;19(4):811-822.
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Affiliation(s)
- Silvia Riccardi
- Sleep Medicine Unit, Regional Hospital of Lugano, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Raffaele Ferri
- Department of Neurology I.C., Oasi Institute for Research on Mental Retardation and Brain Aging (IRCCS), Troina, Italy
| | - Corrado Garbazza
- Sleep Medicine Unit, Regional Hospital of Lugano, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Silvia Miano
- Sleep Medicine Unit, Regional Hospital of Lugano, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Mauro Manconi
- Sleep Medicine Unit, Regional Hospital of Lugano, Neurocenter of Southern Switzerland, Lugano, Switzerland
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Restless Legs Syndrome and Periodic Limb Movements of Sleep: From Neurophysiology to Clinical Practice. J Clin Neurophysiol 2023; 40:215-223. [PMID: 36872500 DOI: 10.1097/wnp.0000000000000934] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
SUMMARY This article summarizes restless legs syndrome (RLS), periodic limb movements of sleep, and periodic limb movement disorder. RLS is a common sleep disorder with a prevalence of 5% to 15% in the general population. RLS can present in childhood, and incidence increases with age. RLS can be idiopathic or secondary to iron deficiency, chronic renal failure, peripheral neuropathy, and medications such as antidepressants (with higher rates for mirtazapine and venlafaxine, while bupropion may reduce symptoms at least in the short term), dopamine antagonists (neuroleptic antipsychotic agents and antinausea medications), and possibly antihistamines. Management includes pharmacologic agents (dopaminergic agents, alpha-2 delta calcium channel ligands, opioids, benzodiazepines) and nonpharmacologic therapies (iron supplementation, behavioral management). Periodic limb movements of sleep are an electrophysiologic finding commonly accompanying RLS. On the other hand, most individuals with periodic limb movements of sleep do not have RLS. The clinical significance of the movements has been argued. Periodic limb movement disorder is a distinct sleep disorder that arises in individuals without RLS and is a diagnosis of exclusion.
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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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14
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Winkelman JW. Treating Severe Refractory and Augmented Restless Legs Syndrome. Chest 2022; 162:693-700. [DOI: 10.1016/j.chest.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/02/2022] [Accepted: 05/14/2022] [Indexed: 10/18/2022] Open
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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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Khachatryan SG, Ferri R, Fulda S, Garcia-Borreguero D, Manconi M, Muntean ML, Stefani A. Restless legs syndrome: Over 50 years of European contribution. J Sleep Res 2022; 31:e13632. [PMID: 35808955 PMCID: PMC9542244 DOI: 10.1111/jsr.13632] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 11/28/2022]
Abstract
Restless legs syndrome (RLS) is a sensorimotor neurological disorder characterised by an urge to move the limbs with a circadian pattern (occurring in the evening/at night), more prominent at rest, and relieved with movements. RLS is one of the most prevalent sleep disorders, occurring in 5%-10% of the European population. Thomas Willis first described RLS clinical cases already in the 17th century, and Karl-Axel Ekbom described the disease as a modern clinical entity in the 20th century. Despite variable severity, RLS can markedly affect sleep (partly through the presence of periodic leg movements) and quality of life, with a relevant socio-economic impact. Thus, its recognition and treatment are essential. However, screening methods present limitations and should be improved. Moreover, available RLS treatment options albeit providing sustained relief to many patients are limited in number. Additionally, the development of augmentation with dopamine agonists represents a major treatment problem. A better understanding of RLS pathomechanisms can bring to light novel treatment possibilities. With emerging new avenues of research in pharmacology, imaging, genetics, and animal models of RLS, this is an interesting and constantly growing field of research. This review will update the reader on the current state of RLS clinical practice and research, with a special focus on the contribution of European researchers.
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Affiliation(s)
- Samson G Khachatryan
- Department of Neurology and Neurosurgery, National Institute of Health, Yerevan, Armenia.,Sleep Disorders Center, Somnus Neurology Clinic, Yerevan, Armenia
| | | | - Stephany Fulda
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland
| | | | - Mauro Manconi
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Ospedale Civico, Lugano, Switzerland.,Department of Neurology, University Hospital, Inselspital, Bern, Switzerland
| | - Maria-Lucia Muntean
- Center for Parkinson's Disease and Movement Disorders, Paracelsus-Elena Klinik, Kassel, Germany
| | - Ambra Stefani
- Sleep Disorders Clinic, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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17
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Schütz L, Sixel-Döring F, Hermann W. Management of Sleep Disturbances in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2022; 12:2029-2058. [PMID: 35938257 PMCID: PMC9661340 DOI: 10.3233/jpd-212749] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 06/07/2023]
Abstract
Parkinson's disease (PD) is defined by its motor symptoms rigidity, tremor, and akinesia. However, non-motor symptoms, particularly autonomic disorders and sleep disturbances, occur frequently in PD causing equivalent or even greater discomfort than motor symptoms effectively decreasing quality of life in patients and caregivers. Most common sleep disturbances in PD are insomnia, sleep disordered breathing, excessive daytime sleepiness, REM sleep behavior disorder, and sleep-related movement disorders such as restless legs syndrome. Despite their high prevalence, therapeutic options in the in- and outpatient setting are limited, partly due to lack of scientific evidence. The importance of sleep disturbances in neurodegenerative diseases has been further emphasized by recent evidence indicating a bidirectional relationship between neurodegeneration and sleep. A more profound insight into the underlying pathophysiological mechanisms intertwining sleep and neurodegeneration might lead to unique and individually tailored disease modifying or even neuroprotective therapeutic options in the long run. Therefore, current evidence concerning the management of sleep disturbances in PD will be discussed with the aim of providing a substantiated scaffolding for clinical decisions in long-term PD therapy.
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Affiliation(s)
- Lukas Schütz
- Department of Neurology, University of Rostock, Rostock, Germany
| | | | - Wiebke Hermann
- Department of Neurology, University of Rostock, Rostock, Germany
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18
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Bae H, Cho YW, Kim KT, Allen RP, Earley CJ. The Safety and Efficacy of Pregabalin Add-on Therapy in Restless Legs Syndrome Patients. Front Neurol 2021; 12:786408. [PMID: 34912291 PMCID: PMC8666621 DOI: 10.3389/fneur.2021.786408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/20/2021] [Indexed: 12/04/2022] Open
Abstract
Pregabalin is increasingly being used as a first-line treatment for symptomatic control of restless legs syndrome (RLS). This study aimed to evaluate the efficacy and safety of pregabalin as add-on therapy in RLS patients already taking dopamine agonists (DA) but still in need of further management. Patients with idiopathic RLS were enrolled, and all had already been prescribed DA for at least 3 months but still had either persistent symptoms, side effects, or comorbid insomnia. An initial dose of 75 mg pregabalin was begun, adjusted as needed, and maintained at a stable dose for 4 weeks, followed by observation for a total of 8 weeks. RLS symptoms and insomnia scores were evaluated before and after add-on pregabalin treatment. Patients were monitored for side effects that could be attributed to pregabalin. A total of 32 RLS patients were enrolled, and 20 subjects remained until the endpoint. After the pregabalin add-on, the mean IRLS score showed significant improvement compared to the baseline (p < 0.001). The insomnia severity index score also improved (p = 0.036), and no serious adverse effects were observed. Our preliminary data suggests the potential for pregabalin as an add-on therapy to DA with regards to both efficacy and safety in patients who have inadequate RLS improvement.
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Affiliation(s)
- Hyoeun Bae
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Yong Won Cho
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Richard P Allen
- Department of Neurology, Hopkins Bayview Medical Center, Johns Hopkins University, Baltimore, MD, United States
| | - Christopher J Earley
- Department of Neurology, Hopkins Bayview Medical Center, Johns Hopkins University, Baltimore, MD, United States
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Basaran S, Akıncı E. Screening autonomic functions in patients with restless legs syndrome: A case-control study in a tertiary care hospital. Auton Neurosci 2021; 237:102924. [PMID: 34871924 DOI: 10.1016/j.autneu.2021.102924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/28/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The clinical importance of autonomic involvement in patients with restless legs syndrome (RLS) remains unclear. To our knowledge, no study has explored the relationship between autonomic dysfunction and disease-related variables in patients with RLS. Therefore, this study aimed 1) to determine the presence of autonomic symptoms in drug-naïve patients with RLS in comparison with healthy controls using Scales for Outcomes in Parkinson's disease-Autonomic (SCOPA-AUT) questionnaire and 2) to evaluate the possible associations of autonomic dysfunction with clinical factors in RLS. METHODS A total of 70 drug-naïve patients with RLS and 85 healthy volunteers were enrolled. The SCOPA-AUT questionnaire and Epworth Sleepiness Scale (ESS) scores were used to determine autonomic functions and sleep propensity, respectively. Moreover, the International Restless Legs Syndrome Study Group rating scale was used to evaluate disease severity in the patient group. RESULTS Compared with the control group, the RLS group had significantly higher subscale scores (gastrointestinal, urinary, cardiovascular, thermoregulatory, pupillomotor, and sexual [women]) and total scores of the SCOPA-AUT questionnaire (p < 0.05). In the patient group, there was a significant correlation between the total scores and subscale scores (gastrointestinal, cardiovascular, and thermoregulatory subscales) of the SCOPA-AUT questionnaire and disease severity. Moreover, ESS was positively correlated with the total scores and subscale scores (urinary, cardiovascular, and pupillomotor) of the SCOPA-AUT questionnaire. CONCLUSION Disease severity and daytime sleepiness may be related to autonomic dysfunction in RLS. Further studies focusing on autonomic functions in RLS are required to improve management strategies and clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov. NCT04906486; May 28, 2021.
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Affiliation(s)
- Sehnaz Basaran
- Department of Neurology, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey.
| | - Erhan Akıncı
- Department of Psychiatry, Canakkale Onsekiz Mart University Medicine Faculty, Canakkale, Turkey.
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20
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Zhou X, Du J, Liang Y, Dai C, Zhao L, Liu X, Tan C, Mo L, Chen L. The Efficacy and Safety of Pharmacological Treatments for Restless Legs Syndrome: Systemic Review and Network Meta-Analysis. Front Neurosci 2021; 15:751643. [PMID: 34764852 PMCID: PMC8576256 DOI: 10.3389/fnins.2021.751643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/29/2021] [Indexed: 01/08/2023] Open
Abstract
Although various drugs are currently used for restless legs syndrome (RLS) in clinic, selecting appropriate drugs for patients is difficult. This network meta-analysis (NMA) aimed to compare the efficacy and safety of different drugs. After literature searching and screening, 46 trials, including 10,674 participants are included in this NMA. The pooled results showed that, compared with placebo, only levodopa is inefficient to relieve symptoms of RLS. Cabergoline decreases IRLS scores to the greatest extent among all drugs (MD −11.98, 95% CI −16.19 to −7.78). Additionally, pramipexole is superior to ropinirole in alleviating symptoms of RLS (MD −2.52, 95% CI −4.69 to −0.35). Moreover, iron supplement alleviates RLS symptoms significantly compared with placebo in patient with iron deficiency (MD −5.15, 95% CI −8.99 to −1.31), but not for RLS patients with normal serum ferritin level (MD −2.22, 95% CI −6.99 to 2.56). For primary RLS, these drugs are also effective, while there is insufficient data to analyze drug efficacy in secondary RLS. We analyzed risk of common adverse effects of drugs including nausea, somnolence, fatigue, headache and nasopharyngitis. Alpha-2-delta ligands and DAs are favorable choices for both primary and secondary RLS because of their significant efficacy and good tolerability. Iron supplement can significantly alleviate symptoms of RLS patients with iron deficiency than placebo. We recommend gabapentin, gabapentin enacarbil, and pregabalin for clinicians for first consideration mainly because that they rarely cause augmentation. Oxycodone-naloxone could be considered in patients with severe or very severe RLS who failed in treatment with above drugs.
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Affiliation(s)
- Xuan Zhou
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Juncong Du
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Liang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chengcheng Dai
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lili Zhao
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Liu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Changhong Tan
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lijuan Mo
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lifen Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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21
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Abstract
Restless legs syndrome (RLS) is a common sensorimotor disorder characterized by an urge to move that appears during rest or is exacerbated by rest, that occurs in the evening or night and that disappears during movement or is improved by movement. Symptoms vary considerably in age at onset, frequency and severity, with severe forms affecting sleep, quality of life and mood. Patients with RLS often display periodic leg movements during sleep or resting wakefulness. RLS is considered to be a complex condition in which predisposing genetic factors, environmental factors and comorbidities contribute to the expression of the disorder. RLS occurs alone or with comorbidities, for example, iron deficiency and kidney disease, but also with cardiovascular diseases, diabetes mellitus and neurological, rheumatological and respiratory disorders. The pathophysiology is still unclear, with the involvement of brain iron deficiency, dysfunction in the dopaminergic and nociceptive systems and altered adenosine and glutamatergic pathways as hypotheses being investigated. RLS is poorly recognized by physicians and it is accordingly often incorrectly diagnosed and managed. Treatment guidelines recommend initiation of therapy with low doses of dopamine agonists or α2δ ligands in severe forms. Although dopaminergic treatment is initially highly effective, its long-term use can result in a serious worsening of symptoms known as augmentation. Other treatments include opioids and iron preparations.
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22
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Winkelman JW. High National Rates of High-Dose Dopamine Agonist Prescribing for RLS. Sleep 2021; 45:6356055. [PMID: 34417810 PMCID: PMC8842153 DOI: 10.1093/sleep/zsab212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/12/2021] [Indexed: 11/14/2022] Open
Abstract
Study Objectives Long-term dopamine agonist (DA) use in restless legs syndrome (RLS) is associated with augmentation, a dose-related symptom worsening leading to further dose escalation to manage RLS. This study investigated rates and factors of high-dose DA prescribing in US RLS patients. Methods This retrospective analysis examined data from a US longitudinal prescriptions database (October 2017–September 2018). Patients diagnosed with RLS (ICD-10 G255.81) without Parkinson’s disease who were prescribed ropinirole, pramipexole, and/or rotigotine were included. Daily DA dosage was categorized: LOW/MID (US Food and Drug Administration [FDA]-approved/guideline or slightly above FDA-approved [pramipexole]); HIGH (101%–149%); VERY HIGH (>150%). Patient counts were converted to US national estimates. Logistic regression of patient counts evaluated factors associated with HIGH/VERY HIGH DA dosing. Results Of 670,404 RLS patients (131,289,331 therapy days), 58.8% were prescribed DA therapy. Overall, 19.1% of RLS patients were prescribed DAs above maximum FDA-approved/guideline daily doses—over half of these were >150% maximum recommended doses; 67.6% of HIGH/VERY HIGH-dose prescriptions were pramipexole (OR [95% CI] pramipexole vs ropinirole, 5.8 [5.7 to 6.0]). The highest 1% of DA prescriptions were ≥10× the FDA-recommended maximum daily dose. Rates of HIGH/VERY HIGH DA dosing increased with patient age. Twice as many neurologists (31.1%) prescribed HIGH/VERY HIGH doses vs other specialties (OR [95% CI], 2.1 [1.2 to 2.0]). Conclusions Approximately 20% of DA-treated RLS patients were prescribed doses above the approved and guideline daily maximum. Pramipexole, Neurology as specialty, and patient age were independently associated with HIGH/VERY HIGH DA dosing. Increased education is warranted regarding risks of high-dose DA exposure in RLS.
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23
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Silber MH, Buchfuhrer MJ, Earley CJ, Koo BB, Manconi M, Winkelman JW. The Management of Restless Legs Syndrome: An Updated Algorithm. Mayo Clin Proc 2021; 96:1921-1937. [PMID: 34218864 DOI: 10.1016/j.mayocp.2020.12.026] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/13/2020] [Accepted: 12/28/2020] [Indexed: 01/26/2023]
Abstract
Restless legs syndrome (RLS) is a common disorder. The population prevalence is 1.5% to 2.7% in a subgroup of patients having more severe RLS with symptoms occurring 2 or more times a week and causing at least moderate distress. It is important for primary care physicians to be familiar with the disorder and its management. Much has changed in the management of RLS since our previous revised algorithm was published in 2013. This updated algorithm was written by members of the Scientific and Medical Advisory Board of the RLS Foundation based on scientific evidence and expert opinion. A literature search was performed using PubMed identifying all articles on RLS from 2012 to 2020. The management of RLS is considered under the following headings: General Considerations; Intermittent RLS; Chronic Persistent RLS; Refractory RLS; Special Circumstances; and Alternative, Investigative, and Potential Future Therapies. Nonpharmacologic approaches, including mental alerting activities, avoidance of substances or medications that may exacerbate RLS, and oral and intravenous iron supplementation, are outlined. The choice of an alpha2-delta ligand as first-line therapy for chronic persistent RLS with dopamine agonists as a second-line option is explained. We discuss the available drugs, the factors determining which to use, and their adverse effects. We define refractory RLS and describe management approaches, including combination therapy and the use of high-potency opioids. Treatment of RLS in pregnancy and childhood is discussed.
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Affiliation(s)
- Michael H Silber
- Center for Sleep Medicine and Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN.
| | - Mark J Buchfuhrer
- Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, CA
| | - Christopher J Earley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brian B Koo
- Department of Neurology, Yale University, New Haven, CT
| | - Mauro Manconi
- Sleep Medicine, Neurocenter of Southern Switzerland, Ospedale Civico, and Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland; Department of Neurology, University Hospital, Inselspital, Bern, Switzerland
| | - John W Winkelman
- Departments of Psychiatry and Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Cambridge, MA
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Abstract
For a long time, dopaminergic treatment (DT) was the medication for restless legs syndrome. Although DT is effective and safe over the short-term, complications develop over longer periods, including augmentation, tolerance, and impulse control disorders. Nowadays, it is recommended that first-line treatment should be alpha-2 ligands, which are more effective in the absence of previous DT. As a second-line treatment, opioids, such as oxycodone extended-release with naloxone, are approved in Europe. Brain iron should be monitored before and during treatment and corrected if necessary. Two new promising non-DTs are being developed: perampanel and dipyridamole. More research is needed.
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Oh SM, Son KL, Choi SJ, Lee MH, Yoon SY, Lee YJ. The seasonal pattern of restless legs syndrome in a sample from the Korean Health Insurance Review and Assessment Service national database. J Clin Sleep Med 2021; 17:1051-1056. [PMID: 33570488 DOI: 10.5664/jcsm.9136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To assess the seasonality of restless legs syndrome (RLS) using data from the Korean national health insurance database. METHODS We retrospectively reviewed a randomly selected sample representing 3% of the national health insurance claims database in South Korea. From this sample, we obtained the monthly numbers of patients with RLS and diagnoses from 2009 to 2016, along with prescriptions for monthly dopamine agonists and clonazepam for patients with RLS from 2009 to 2013. Total dopamine agonist and clonazepam doses were converted to levodopa-equivalent doses, and the monthly cumulative prescription dose was calculated. Cosinor analysis was used to evaluate the seasonal pattern of each variable. RESULTS This study included 11,466 patients with RLS and their diagnoses and 4,887 prescriptions for dopamine agonists and clonazepam. There were significant seasonal patterns in the numbers of patients with RLS (P < .001) and diagnoses (P < .001), both of which peaked in August. The magnitude of the greatest difference in the number of patients with RLS between August (highest) and February (lowest) was 29.96% (95% confidence interval, 24.03-100.80), and that of the number of RLS diagnoses was 39.56% (95% confidence interval, 31.24-47.89). The cumulative prescription dose of medication showed no significant seasonality. CONCLUSIONS Our findings suggest that the prevalence of RLS is seasonally affected, with an increase during summer.
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Affiliation(s)
- Seong Min Oh
- Department of Psychiatry, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Kyung-Lak Son
- Department of Psychiatry, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Seok-Jin Choi
- Department of Neurology, Inha University School of Medicine, Incheon, Republic of Korea
| | - Mi Hyun Lee
- Department of Psychiatry and Center for Sleep and Chronobiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - So Young Yoon
- Department of Psychiatry and Center for Sleep and Chronobiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yu Jin Lee
- Department of Psychiatry and Center for Sleep and Chronobiology, Seoul National University Hospital, Seoul, Republic of Korea
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Wang T, Ying M, Zhao R, Zhu D, Zhang L. Augmentation in patients with restless legs syndrome receiving pramipexole therapy: a retrospective study in a single center from China. Sleep Breath 2021; 26:373-380. [PMID: 33864178 DOI: 10.1007/s11325-021-02353-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/13/2021] [Accepted: 03/15/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Augmentation is a major complication of long-term pramipexole treatment of restless legs syndrome (RLS). However, there have been no studies on augmentation in Chinese patients with RLS. We therefore investigated the clinical characteristics of augmentation in RLS patients treated with pramipexole in a real-world Chinese setting. METHODS This study was an observational, retrospective assessment of 103 patients with RLS, who had been continuously treated with pramipexole for at least one month between January 2016 and December 2018 in a tertiary hospital in East China. Demographic data and disease and drug treatment information were collected from electronic medical records and telephone interviews to analyze the rate and clinical features of augmentation. Augmentation was confirmed by Max Planck Institute criteria. Comparisons were made between patients with and without augmentation. RESULTS Fifteen patients (15%) were classified as having augmentation. Compared to RLS patients without augmentation, more patients with augmentation switched from other dopaminergic drugs (P<0.05) and had a longer duration of RLS symptoms before pramipexole treatment (P<0.05). In addition, patients with augmentation had a longer duration (P<0.05) and higher dosage (P<0.05) of pramipexole than those without augmentation. Augmentation was possibly associated with pramipexole tolerance (P<0.01). CONCLUSION The augmentation rate of the Chinese RLS patients in our study was 15%. Augmentation may be associated with switching from other dopaminergic drugs, long disease duration before pramipexole use, the dose and duration of pramipexole, and tolerance to pramipexole.
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Affiliation(s)
- Tiantian Wang
- Department of Pharmacy, Xiasha Campus, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 368 Rd Xiasha, Zhejiang Province, 310016, Hangzhou, China
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Science, Zhejiang University, No. 866 Rd Yuhangtang, Zhejiang Province, 310058, Hangzhou, China
- Center for Sleep Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Rd East Qingchun, Zhejiang Province, 310016, Hangzhou, China
| | - Miaofa Ying
- Department of Pharmacy, Xiasha Campus, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 368 Rd Xiasha, Zhejiang Province, 310016, Hangzhou, China
| | - Rui Zhao
- Department of Pharmacy, Xiasha Campus, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 368 Rd Xiasha, Zhejiang Province, 310016, Hangzhou, China
| | - Danyan Zhu
- Institute of Pharmacology and Toxicology, College of Pharmaceutical Science, Zhejiang University, No. 866 Rd Yuhangtang, Zhejiang Province, 310058, Hangzhou, China.
| | - Lisan Zhang
- Center for Sleep Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Rd East Qingchun, Zhejiang Province, 310016, Hangzhou, China.
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Rd East Qingchun, Zhejiang Province, 310016, Hangzhou, China.
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Mohiuddin O, Khan AA, Shah SMI, Malick MDZ, Memon SF, Jalees S, Yasmin F. New-onset restless leg syndrome in a COVID-19 patient: a case report with literature review. Pan Afr Med J 2021; 38:318. [PMID: 34285741 PMCID: PMC8265268 DOI: 10.11604/pamj.2021.38.318.28836] [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: 03/12/2021] [Accepted: 03/21/2021] [Indexed: 12/15/2022] Open
Abstract
Restless leg syndrome (RLS) is a sleep disorder characterized by the sudden urge to move the lower limbs during periods of rest accompanied by an unpleasant sensation like tingling or burning in the legs. Often, this urge is partially relieved by the movement of legs. However, it causes disturbance of sleep leading to daytime fatigue. Herein, we present an unusual case of new-onset of restless leg syndrome in a COVID-19 infected patient who presented three weeks after an uncomplicated delivery via caesarean section. The patient was managed with sleep hygiene measures, oral iron and vitamin C tablets apart from general COVID-19 management medications, subsequently leading to significant improvements. Here we have discussed possible associated factors, pathophysiological mechanisms and management of RLS in the case of COVID infected individuals.
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Affiliation(s)
- Osama Mohiuddin
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Anosh Aslam Khan
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | | | | | - Sumeen Jalees
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Farah Yasmin
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
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Katunina EA, Titova NV, Katunin DA, Bagmanyan SD, Pogorova AR. [Restless legs syndrome]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:106-113. [PMID: 33728859 DOI: 10.17116/jnevro2021121021106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Restless legs syndrome (RLS) is seen widely in clinical practice. RLS commonly occurs at night time and presents with unpleasant or uncomfortable sensations in the legs that causes an urge to move them. This article describes the epidemiology, risk factors and pathophysiology of RLS. There is a detailed description of clinical presentations, diagnostic criteria and also management of RLS.
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Affiliation(s)
- E A Katunina
- Pirogov Russian National Research Medical University, Moscow, Russia.,Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - N V Titova
- Pirogov Russian National Research Medical University, Moscow, Russia.,Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - D A Katunin
- Pirogov Russian National Research Medical University, Moscow, Russia.,Federal Center of Brain Research and Neurotechnologies, Moscow, Russia
| | - S D Bagmanyan
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A R Pogorova
- Pirogov Russian National Research Medical University, Moscow, Russia
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29
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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] [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)
- Qing Lv
- Department of Neurology, TongRen Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xinlin Wang
- Department of Neurology, TongRen Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Tetsuya Asakawa
- Department of Neurosurgery, Hamamatsu University School of Medicine, Handayama, 1-20-1, Higashi-ku, Hamamatsucity, Shizuoka 431-3192, Japan
| | - Xiao Ping Wang
- Department of Neurology, TongRen Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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30
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Gossard TR, Trotti LM, Videnovic A, St Louis EK. Restless Legs Syndrome: Contemporary Diagnosis and Treatment. Neurotherapeutics 2021; 18:140-155. [PMID: 33880737 PMCID: PMC8116476 DOI: 10.1007/s13311-021-01019-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 12/12/2022] Open
Abstract
Restless legs syndrome (RLS) is characterized by an uncomfortable urge to move the legs while at rest, relief upon movement or getting up to walk, and worsened symptom severity at night. RLS may be primary (idiopathic) or secondary to pregnancy or a variety of systemic disorders, especially iron deficiency, and chronic renal insufficiency. Genetic predisposition with a family history is common. The pathogenesis of RLS remains unclear but is likely to involve central nervous system dopaminergic dysfunction, as well as other, undefined contributing mechanisms. Evaluation begins with a thorough history and examination, and iron measures, including ferritin and transferrin saturation, should be checked at presentation and with worsened symptoms, especially when augmentation develops. Augmentation is characterized by more intense symptom severity, earlier symptom occurrence, and often, symptom spread from the legs to the arms or other body regions. Some people with RLS have adequate symptom control with non-pharmacological measures such as massage or temperate baths. First-line management options include iron-replacement therapy in those with evidence for reduced body-iron stores or, alternatively, with prescribed gabapentin or pregabalin, and dopamine agonists such as pramipexole, ropinirole, and rotigotine. Second-line therapies include intravenous iron infusion in those who are intolerant of oral iron and/or those having augmentation with intense, severe RLS symptoms, and opioids including tramadol, oxycodone, and methadone. RLS significantly impacts patients' quality of life and remains a therapeutic area sorely in need of innovation and a further pipeline of new, biologically informed therapies.
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Affiliation(s)
- Thomas R Gossard
- Mayo Center for Sleep Medicine, 200 First Street SW, Rochester, MN, 55905, USA
| | | | | | - Erik K St Louis
- Mayo Center for Sleep Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
- Departments of Neurology and Clinical and Translational Research, Mayo Clinic Southwest Wisconsin, La Crosse, Wisconsin, USA.
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31
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Tarulli A. Distal and Generalized Sensory Symptoms. Neurology 2021. [DOI: 10.1007/978-3-030-55598-6_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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32
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Collister D, Pohl K, Herrington G, Lee SF, Rabbat C, Tennankore K, Zimmermann D, Tangri N, Wald R, Manns B, Suri RS, Nadeau-Fredette AC, Goupil R, Silver SA, Walsh M. The DIalysis Symptom COntrol-Restless Legs Syndrome (DISCO-RLS) Trial: A Protocol for a Randomized, Crossover, Placebo-Controlled Blinded Trial. Can J Kidney Health Dis 2020; 7:2054358120968959. [PMID: 33294203 PMCID: PMC7705292 DOI: 10.1177/2054358120968959] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/11/2020] [Indexed: 11/17/2022] Open
Abstract
Background Restless legs syndrome (RLS) affects approximately 30% of patients with end-stage kidney disease and is associated with impaired sleep and health-related quality of life. Medications used to treat RLS in patients receiving dialysis may have an increased risk of adverse events with dose titration, and residual RLS symptoms are common despite the use of effective treatments. Randomized controlled trials of monotherapy and combination pharmacologic therapy for RLS in hemodialysis are needed. Objective To perform a randomized, crossover, placebo-controlled blinded trial of pharmacologic therapy for RLS in hemodialysis. Design/setting The DIalysis Symptom COntrol-Restless Legs Syndrome (DISCO-RLS) trial is a randomized, crossover, placebo-controlled blinded trial of fixed low-dose pharmacologic therapy in patients receiving hemodialysis in 10 centers across Canada. It uses patient partners in its design, conduct, and reporting. Participants Adults receiving thrice-weekly hemodialysis for at least 3 months with RLS of at least mild symptoms defined International Restless Legs Syndrome Study Group Rating Scale (IRLS) of 10 or more will enter a double placebo run-in period to exclude nonadherent participants and those unable to tolerate double placebo. Seventy-two participants who completed the run-in period will be randomized to 1 of 8 treatment sequences based on modeling with 4 treatment periods. Methods Each treatment period lasts 4 weeks and consists of ropinirole 0.5 mg daily and gabapentin 100 mg daily, both together or neither with a double dummy placebo control for each treatment. The primary outcome is the difference in change scores of the IRLS between study treatments. Secondary outcomes are the differences in change scores of the Restless Legs Syndrome-6 Scale, patient global impression, 5-level EQ-5D version, and safety outcomes. Results This randomized, crossover, placebo-controlled blinded trial will evaluate the efficacy and safety of fixed low-dose combination of ropinirole and gabapentin in patients receiving hemodialysis with RLS. Limitations Patients with chronic kidney disease not on dialysis, kidney transplant recipients and those receiving peritoneal dialysis or home hemodialysis are not included. The intervention's long term safety and efficacy including the risk of augmentation is not captured. Conclusion This randomized crossover placebo controlled blinded trial will evaluate the efficacy and safety of fixed low-dose combination ropinirole and gabapentin in patients receiving hemodialysis with RLS. Trial Registration ClinicalTrials.gov (NCT03806530).
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Affiliation(s)
- David Collister
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kayla Pohl
- Population Health Research Institute, Hamilton, ON, Canada
| | - Gwen Herrington
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD), Vancouver, BC, Canada
| | - Shun Fu Lee
- Population Health Research Institute, Hamilton, ON, Canada
| | - Christian Rabbat
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Navdeep Tangri
- Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Ron Wald
- Department of Medicine, University of Toronto, ON, Canada
| | - Braden Manns
- Department of Medicine and Community Health Sciences, University of Calgary, AB, Canada
| | - Rita S Suri
- Department of Medicine, McGill University, Montréal, QC, Canada.,Centre de Recherche, Université de Montréal, QC, Canada
| | | | - Remi Goupil
- Faculté de Médecine, Université de Montréal, QC, Canada
| | - Samuel A Silver
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Michael Walsh
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
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Akhmadulina AO, Levin OS, Poluektov MG. [Restless legs syndrome in Parkinson's disease]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:80-88. [PMID: 33205935 DOI: 10.17116/jnevro202012010280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Disturbances in sleep and wakefulness are important symptoms of Parkinson's disease (PD) and are associated with negative effects on patients' quality of life. The analysis of literature on the relationship between RLS and PD revealed three main hypotheses explaining the relatively high incidence of RLS in PD: (1) RLS can be considered as an early (prodromal) manifestation or a predictor of PD that can outpace its main symptoms by several years (by analogy with conduct disorder during sleep with REM); (2) the high incidence of RLS in the advanced stage of PD may be associated with augmentation of previously latent RLS symptoms during prolonged dopaminergic therapy of PD; (3) a significant proportion of RLS cases in PD patients are not «classical» RLS, but represent, for example, manifestations of motor or non-motor fluctuations or a special form of stereotypy in the legs. Further research is needed to determine if any of these statements are true.
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Affiliation(s)
- A O Akhmadulina
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - O S Levin
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - M G Poluektov
- Sechenov First Moscow Medical University, Moscow, Russia
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34
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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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35
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Safarpour Y, Vaziri ND, Jabbari B. Movement Disorders in Chronic Kidney Disease - A Descriptive Review. J Stroke Cerebrovasc Dis 2020; 30:105408. [PMID: 33139171 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105408] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/19/2020] [Accepted: 10/12/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES The objective of this study is to describe the mechanism of damage to subcortical structures in chronic kidney disease (CKD) and to describe the range of movement disorders associated with CKD. MATERIALS AND METHODS We have reviewed the Medline literature up to January of 2020 using key words movement disorders and chronic kidney disease. The reviewed articles were studied for mechanisms of subcortical damage in CKD as well as type of the reported movements, their frequency and updated treatment. RESULTS The search revealed 183 articles most of them dealing with restless legs syndrome. The damage to basal ganglia in CKD resulted from several mechanisms including accumulation of nitro tyrosine caused by reactive oxygen species and action of uremic toxins leading to endothelial damage and dysfunction of blood-brain barrier. Involuntary movements in CKD include restless legs syndrome (RLS), myoclonus, asterixis, dystonia, chorea, tremor, and Parkinsonism. CONCLUSIONS Chronic kidney disease can cause several abnormal involuntary movements via damaging basal ganglia and subcortical structures. The most common movement disorders in CKD are RLS, myoclonus and asterixis. Restless legs syndrome and myoclonus when severe, need and respond to treatment. Movement disorders in CKD improve with improvement of kidney function.
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Affiliation(s)
- Yasaman Safarpour
- Department of Medicine. University of California Riverside, School of Medicine, United States.
| | - Nosratola D Vaziri
- Division of Nephrology, Department of Medicine, University of California Irvine, United States.
| | - Bahman Jabbari
- Division of Movement Disorders, Department of Neurology, Yale University School of Medicine, United States.
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36
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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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37
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Morais MA, Franco B, Holanda ASS, Simino LADP, Manconi M, Torsoni A, Esteves AM. PTPRD as a candidate druggable target for therapies for restless legs syndrome? J Sleep Res 2020; 30:e13216. [PMID: 33111449 DOI: 10.1111/jsr.13216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022]
Abstract
The gene that encodes the protein tyrosine phosphatase D (PTPRD) may be related to brain circuits associated with sleep, and has been seen as an interesting molecule, a "druggable" drug target. This gene is a potential candidate for increasing therapeutic advances in restless legs syndrome, a sleep-related movement disorder, that manifests as an uncontrollable desire to move limbs (legs) to relieve uncomfortable sensations. Changes in the PTPRD gene expression may increase the chance of developing this syndrome. Treatment with pramipexole is used in restless legs syndrome. This study aims to verify the effect of treatment with pramipexole on the PTPRD expression, as well as on the sleep pattern in an animal model for restless legs syndrome. For this, an animal model of sleep-related movement disorders (spontaneously hypertensive rats) was distributed in groups: (a) spontaneously hypertensive rats-control; (b) spontaneously hypertensive rats-pramipexole (0.125 mg kg-1 for 4 weeks). The analyses of PTPRD gene and protein expression were performed in the striatum and spinal cord by quantitative real-time polymerase chain reaction and indirect enzyme-linked immunosorbent assay, respectively. Electrocorticographic and electromyographic analyses were performed. There was no difference in the PTPRD mRNA levels, as well as in the protein levels, although a tendency has been observed for decreased gene expression in the striatum and increased protein expression in the spinal cord in the spontaneously hypertensive rats-pramipexole group. Pramipexole improved the animals' sleep pattern. Thus, the treatment with pramipexole in the evaluated dose and time tended to alter the expression of the PTPRD protein in the spinal cord, in addition to significantly improving the sleep pattern.
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Affiliation(s)
- Milca A Morais
- Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Limeira, Brazil
| | - Beatriz Franco
- Faculdade de Educação Física, Universidade Estadual de Campinas, Campinas, Brazil
| | | | | | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano (EOC), Lugano, Switzerland
| | - Adriana Torsoni
- Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Limeira, Brazil
| | - Andrea M Esteves
- Faculdade de Ciências Aplicadas, Universidade Estadual de Campinas, Limeira, Brazil
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Zuzuárregui JRP, During EH. Sleep Issues in Parkinson's Disease and Their Management. Neurotherapeutics 2020; 17:1480-1494. [PMID: 33029723 PMCID: PMC7851262 DOI: 10.1007/s13311-020-00938-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 12/13/2022] Open
Abstract
Parkinson's disease (PD) is an alpha-synucleinopathy that leads to prominent motor symptoms including tremor, bradykinesia, and postural instability. Nonmotor symptoms including autonomic, neurocognitive, psychiatric symptoms, and sleep disturbances are also seen frequently in PD. The impact of PD on sleep is related to motor and nonmotor symptoms, in addition to the disruption of the pathways regulating sleep by central nervous system pathology. Rapid eye movement sleep behavior disorder is a parasomnia that can lead to self-injury and/or injury to partners at night. Restless legs syndrome is a subjective sensation of discomfort and urge to move the legs prior to falling asleep and can lead to insomnia and reduced sleep quality. Excessive daytime sleepiness is common in PD and exerts a negative impact on quality of life in addition to increasing the risk of falls. Obstructive sleep apnea is a breathing disorder during sleep that can cause frequent awakenings and excessive daytime sleepiness. Circadian rhythm dysfunction can lead to an advanced or delayed onset of sleep in patients and create disruption of normal sleep and wake times. All of these disorders are common in PD and can significantly reduce sleep quantity, sleep quality, or quality of life for patients and caretakers. Treatment approaches for each of these disorders are distinct and should be individualized to the patient. We review the literature regarding these common sleep issues encountered in PD and their treatment options.
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Affiliation(s)
| | - Emmanuel H During
- Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center, Palo Alto, CA, USA
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39
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Rémi J. [Not Available]. MMW Fortschr Med 2020; 162:54-59. [PMID: 32895836 DOI: 10.1007/s15006-020-1214-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Jan Rémi
- Klinikum Großhadern d. LMU München, Marchioninistr. 15, 81377, München, Germany.
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40
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Garcia-Malo C, Peralta SR, Garcia-Borreguero D. Restless Legs Syndrome and Other Common Sleep-Related Movement Disorders. Continuum (Minneap Minn) 2020; 26:963-987. [PMID: 32756231 DOI: 10.1212/con.0000000000000886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW In this article, the different sleep-related movement disorders are discussed with special attention given to restless legs syndrome (RLS). RECENT FINDINGS The differential diagnosis of sleep-related movement disorders can often be challenging; therefore, it is essential to have accurate information to make a correct diagnosis. This article focuses on RLS, highlighting the change in the paradigm of initial treatment, the role played by iron (pathophysiologic and therapeutic), and how to approach possible complications occurring with long-term treatment. SUMMARY RLS is one of the most common neurologic conditions, and it is common in clinical practice to find patients experiencing symptoms suggestive of RLS. Neurologists must be careful and thorough in the diagnosis, excluding RLS mimics. The decisions regarding which specific sleep-related movement disorder is present and how it should be treated are important because in certain cases, especially in RLS, adverse effects and long-term complications are frequently reported with the use of certain drugs.
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Convergence of psychiatric symptoms and restless legs syndrome: A cross-sectional study in an elderly French population. J Psychosom Res 2020; 128:109884. [PMID: 31794908 DOI: 10.1016/j.jpsychores.2019.109884] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 11/14/2019] [Accepted: 11/24/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The objective was to evaluate the association between restless legs syndrome (RLS) with generalized anxiety disorder (GAD), major depression disorder (MDD), dysthymia, and GAD-depression comorbidity. Secondary aims were to examine the association between RLS with the cognitive-affective and somatic-vegetative disturbances experienced as part of depression and GAD. METHODS This was a cross-sectional study of 1493 elderly participants (median age 80.6 years, 64% women) from Dijon, France. Probable RLS was assessed using the minimal diagnostic criteria of the International Restless Legs Study Group and RLS symptom frequency and treatment. Participants underwent structured interviews for MDD, dysthymia, and GAD. Participants also completed the Center for Epidemiological Studies-Depression scale (CES-D). The association between RLS and psychiatric disorders, their criterion symptoms, or symptom factors was examined using logistic regression. RESULTS The point prevalence of probable RLS in this sample was 8.2%. Probable RLS was associated with isolated GAD (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.01-4.68) and comorbid GAD-any depression disorder (OR 3.26, 95% CI 1.14-9.29), but not MDD or dysthymia. Probable RLS was also associated with the GAD criterion worry most days and feeling tense, and the CES-D factors representing depressed affect, somatic symptoms, and positive affect. CONCLUSIONS Probable RLS was associated with GAD-depression comorbidity as well as isolated GAD. The findings challenge previous reports linking RLS solely with MDD, suggesting the association is partly driven by GAD-depression comorbidity.
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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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43
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Keir LHM, Breen DP. New awakenings: current understanding of sleep dysfunction and its treatment in Parkinson's disease. J Neurol 2019; 267:288-294. [PMID: 31807917 PMCID: PMC6954899 DOI: 10.1007/s00415-019-09651-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/23/2019] [Indexed: 12/22/2022]
Abstract
The non-motor features of Parkinson’s disease (PD) are increasingly being recognised. This review deals with the spectrum of sleep disorders associated with PD, which have a multifactorial aetiology and can significantly have an impact on the quality of life of patients and their carers. Some sleep disorders represent a prodromal phase of PD, with REM sleep behaviour disorder (RBD) being of particular interest in this regard, whereas others become more common as the disease advances. Understanding the pathophysiology of these sleep disturbances will hopefully lead to new treatment opportunities in the future. The recent discovery of the glymphatic system for removal of waste products from the brain has also raised the possibility that sleep disruption may cause or accelerate the underlying disease process.
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Affiliation(s)
- Lindsay H M Keir
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - David P Breen
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK. .,Centre for Clinical Brain Sciences, University of Edinburgh, Room FU303g, Chancellor's Building, 49 Little France Crescent, Edinburgh, E16 4SB, UK. .,Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Edinburgh, UK. .,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
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45
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Rémi J, Pollmächer T, Spiegelhalder K, Trenkwalder C, Young P. Sleep-Related Disorders in Neurology and Psychiatry. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:681-688. [PMID: 31709972 PMCID: PMC6865193 DOI: 10.3238/arztebl.2019.0681] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/07/2019] [Accepted: 07/24/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Sleep-related disorders are a group of illnesses with marked effects on patients' quality of life and functional ability. Their diagnosis and treatment is a matter of common interest to multiple medical disciplines. METHODS This review is based on relevant publications retrieved by a selective search in PubMed (Medline) and on the guide- lines of the German Society for Sleep Medicine, the German Neurological Society, and the German Association for Psychiatry, Psychotherapy and Psychosomatics. RESULTS A pragmatic classification of sleep disorders by their three chief complaints-insomnia, daytime somnolence, and sleep-associated motor phenomena-enables tentative diagnoses that are often highly accurate. Some of these disorders can be treated by primary care physicians, while others call for referral to a neurologist or psychiatrist with special experience in sleep medicine. For patients suffering from insomnia as a primary sleep disorder, rather than a symptom of another disease, meta-analyses have shown the efficacy of cognitive behavioral therapy, with high average effect sizes. These patients, like those suffering from secondary sleep disorders, can also benefit from drug treatment for a limited time. Studies have shown marked improvement of sleep latency and sleep duration from short-term treatment with benzodiazepines and Z-drugs (non- benzodiazepine agonists such as zolpidem and zopiclone), but not without a risk of tolerance and dependence. For sleep disorders with the other two main manifestations, specific drug therapy has been found to be beneficial. CONCLUSION Sleep disorders in neurology and psychiatry are a heterogeneous group of disorders with diverse manifestations. Their proper diagnosis and treatment can help prevent secondary diseases and the worsening of concomitant conditions. Care structures for the treatment of sleep disorders should be further developed.
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Affiliation(s)
- Jan Rémi
- Department of Neurology, Medical Center of the Ludwig-Maximilians–University of Munich (LMU), Germany
| | | | - Kai Spiegelhalder
- Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, Medical Faculty, University of Freiburg, Germany
| | - Claudia Trenkwalder
- Center of Parkinsonism and Movement Disorders, Paracelsus-Elena Hospital, Kassel, Germany and Department of Neurosurgery, University Medical Center Göttingen, Germany
| | - Peter Young
- Specialized Clinic for Therapies in Neurology, Medical Park Reithofpark, Bad Feilnbach, Germany
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Romero-Peralta S, Cano-Pumarega I, Garcia-Malo C, Agudelo Ramos L, García-Borreguero D. Treating restless legs syndrome in the context of sleep disordered breathing comorbidity. Eur Respir Rev 2019; 28:28/153/190061. [PMID: 31578212 PMCID: PMC9488714 DOI: 10.1183/16000617.0061-2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/31/2019] [Indexed: 12/03/2022] Open
Abstract
Obstructive sleep apnoea (OSA) and restless legs syndrome (RLS) are two of the most prevalent sleep disorders and can coexist within the same patient. Nonetheless, the recognition of RLS among OSA patients has important clinical implications, since RLS can disrupt sleep despite adequate treatment of sleep disordered breathing and should be treated accordingly. Furthermore, the presence of OSA can also increase the severity of RLS. Therefore, it is important to be able to correctly identify both disorders and treat them effectively. The present article reviews our current knowledge on this comorbidity and discusses potential treatment options for RLS in the context of OSA. Treating restless legs syndrome in the context of sleep disordered breathing comorbidityhttp://bit.ly/2lUgFcT
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Abstract
Sleep disorders are common among PD patients and affect quality of life. They are often under-recognized and under-treated. Mechanisms of sleep disorders in PD remain relatively poorly understood. Improved awareness of common sleep problems in PD. Tailored treatment and evidence for efficacy are lacking. The purpose of this review is to provide an overview and update on the most common sleep disorders in PD. We review specific features of the most common sleep disorders in PD, including insomnia, excessive daytime sleepiness, sleep-disordered breathing, restless legs syndrome, circadian rhythm disorders and REM sleep behavior disorders.
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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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[Frequent neurological diseases associated with the restless legs syndrome]. DER NERVENARZT 2019; 89:1156-1164. [PMID: 29736677 DOI: 10.1007/s00115-018-0528-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Restless legs syndrome (RLS) is a common neurological disease. Studies have shown that RLS is associated with a variety of medical and neurological disorders. OBJECTIVES Using the example of three associated neurological diseases, the significance for everyday therapy decisions is assessed. MATERIAL AND METHODS A systematic search was carried out in PubMed for all studies with the keyword "RLS" in combination with polyneuropathies (PNP), Parkinson's disease (PD) and multiple sclerosis (MS) and classified according to the methodology in high, medium or low study quality. RESULTS Of 16 studies on RLS and MS, 10 were rated as "high". The high association frequency of RLS in MS between 13.3% and 65.1% (the variability possibly originates from different methods) prevents further statements about the prevalence. Within 30 studies on Parkinson's disease 17 were classified as having a high quality. In patients with Parkinson disease RLS occurs most frequently during therapy and is related to the duration of dopaminergic treatment. In patients with polyneuropathy, only 5 out of 24 studies were classified as being of high quality and an increased RLS prevalence was detected for acquired polyneuropathies with heterogeneous data for hereditary forms. CONCLUSION There is an increased prevalence of association with RLS for the diseases discussed. This prevalence is possibly determined by the pathophysiology of these disorders. These diseases are possibly characterized by genetic predispositions as well, which can hopefully be classified more accurately in the future.
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Zhuang S, Na M, Winkelman JW, Ba D, Liu CF, Liu G, Gao X. Association of Restless Legs Syndrome With Risk of Suicide and Self-harm. JAMA Netw Open 2019; 2:e199966. [PMID: 31441941 PMCID: PMC6714009 DOI: 10.1001/jamanetworkopen.2019.9966] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Restless legs syndrome (RLS) is a common neurologic disorder that has been previously found to be associated with higher odds of suicidal ideation. In the context of the increasing suicide rate in the United States, the evidence regarding the association between RLS and the risk of suicide and self-harm is limited. OBJECTIVE To investigate the association between RLS and risk of suicide and self-harm. DESIGN, SETTING, AND PARTICIPANTS This cohort study was performed using Truven Health MarketScan national claims data from 2006 to 2014; the baseline data were from 2006 to 2008, and the follow-up data covered 6 years (January 1, 2009, to December 31, 2014). Included were 24 179 nonpregnant participants with RLS and 145 194 age- and sex-matched participants without RLS at baseline (2006-2008), who were free of suicide, self-harm, cardiovascular disease, or cancer at study baseline. Data analysis was performed from February 1, 2018, to January 1, 2019. EXPOSURE Diagnosis of RLS, as identified by the International Classification of Diseases, Ninth Revision code. MAIN OUTCOMES AND MEASURES Incident suicide and self-harm event, identified by the International Classification of Diseases, Ninth Revision diagnosis code. RESULTS Among 169 373 participants in the current analysis, the mean (SD) age was 49.4 (9.1) years; 53 426 (31.5%) participants were men. During a mean (SD) follow-up duration of 5.2 (2.2) years, 119 incident suicide and self-harm cases were identified. Individuals with RLS had a higher risk of suicide or self-harm compared with those without RLS (adjusted hazard ratio, 2.66; 95% CI, 1.70-4.15), after adjusting for lifestyle factors (eg, alcohol and obesity), presence of chronic diseases (eg, depression, insomnia, diabetes, chronic kidney disease, peripheral neuropathy, iron-deficiency anemia, and Parkinson disease), and use of medications. Excluding those with depression, insomnia, obstructive sleep apnea, and other common chronic conditions, the significant association between RLS and suicide or self-harm persisted (adjusted hazard ratio, 4.14; 95% CI, 2.17-7.92). CONCLUSIONS AND RELEVANCE Restless legs syndrome was associated with a high risk of suicide and self-harm, and the risk was independent of most identified diseases and conditions.
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Affiliation(s)
- Sheng Zhuang
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Muzi Na
- Department of Nutritional Sciences, Pennsylvania State University, State College, University Park
| | - John W. Winkelman
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Djibril Ba
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey
| | - Chun-Feng Liu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Guodong Liu
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey
| | - Xiang Gao
- Department of Nutritional Sciences, Pennsylvania State University, State College, University Park
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