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Unhappy Feet: Restless Leg Syndrome Bob Marshall, MD MPH MISM CAPT MC USN Director of Clinical Informatics US Navy Bureau of Medicine and Surgery, Washington, DC Objectives for Today • Define the syndrome • Review prevalence and diagnostic criteria • Review impact on QoL • Discuss how to make the diagnosis • Review treatment • Review prognosis • Summarize and provide take-home message Definition • Restless legs syndrome (RLS) is a sensorimotor disorder typically characterized by an uncomfortable feeling in the legs that leads to an urge to move • A clinical diagnosis made in the office, not in the sleep laboratory • Diagnosis is based on a careful history Kushida, CA. 2007. Prevalence • Numerous survey and epidemiological studies done • Prevalence ranges from 7-10 % with symptoms at least once per week • Ethnic and geographic variations • Women more affected than men: approx 2:1 • Iron deficiency, pregnancy, family hx and renal dz increase risk Gamaldo, CE and Earley, CJ. 2006. Interesting Facts • Two types: idiopathic and secondary – Idiopathic, more prevalent, found in younger patients and felt to be familial – Secondary due to Fe deficiency, pregnancy, renal failure, poor gut Fe absorption (surgery) • Seen at any age, but young children uncommon • Once have symptoms, they persist Prevalence increases with age Allen, RP. 2007. Diagnostic Criteria • An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs • The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity such as lying or sitting • The urge to move or unpleasant sensations are partially or totally relieved by movement • The urge to move or unpleasant sensations are worse in the evening or night than during the day or only occur in the evening or night Allen, RA. 2003. Impact on QoL • In large population study, moderate or severely distressing symptoms at least twice a week were experienced 2.7%. • All eight domains of the SF-36 QoL questionnaire had significantly lower scores than age and sex adjusted US population • Actual values very similar to those with type 2 diabetes or osteoarthritis Reese, JP, et al. 2007; Allen, RP, et al. 2005. Effects on Work/Daily Activities Economic Burden • Almost all costs outpatient and lost work • RLS patients had 1.5-2.0x costs versus age and sex matched controls • Using IRLS criteria, a 1.728 increase on IRLS scale equaled 1% increase in work dysfunction • Studies indicate RLS costs similar to other chronic diseases Curtice, TG, et al. 2006.; Douzinas, N, et al. 2005. Making the Diagnosis 1 of 2 • Need to ask the questions, especially of patients presenting with sleep problems • Only 25% of patients with RLS are accurately diagnosed • Diagnosis more difficult in children and cognitively impaired elderly patients • Medical, physical and neurological exams in primary RLS are all normal Making the Diagnosis 2 of 2 • Secondary causes of RLS can be detected – Iron studies for Fe deficiency (ferritin & iron saturation levels) – Renal studies for ESRD – Pregnancy test (only if possible missed pregnancy) • Polysomnography and Suggested Immobilization Test (SIT) not diagnostic Kushida, CA. 2007. Differential Diagnosis • Neuropathic pain syndromes • Peripheral neuropathy • Arthritis • Nocturnal leg cramps • Restless insomnia • Painful legs and moving toes • Vascular insufficiencies • Drug-induced akathisia Comorbidities • Back pain • Depression/depressed mood • Hypertension • Insomnia • Anxiety • Arthritis • Nocturnal cramps Non-Pharmacologic Treatment • Find and treat underlying disorders • Avoid RLS precipitants (medications) – SSRI’s, TCA’s, dopamine-blocking agents • Good sleep hygiene • Lifestyle modifications: walk before bed, hot bath/cold shower, limb massage • Moderate exercise • Weight management Hening, WA. 2007. Pharmacologic Treatment 1 of 3 • Intermittent RLS symptoms – Medications that can be taken as needed – Levodopa with decarboxylase inhibitor (carbidopa or benserazide) – Mild- to moderate-strength opioid (codeine, propoxyphene, tramadol, hydrocodone, oxycodone) – Sedative-hypnotics – Dopamine agonist: low dose, if tolerated Hering, WA. 2007. ; RLS Foundation Pharmacologic Treatment 2 of 3 • Daily RLS symptoms – Dopamine agonists: ropinirole, pramipexole – Anticonvulsants: gabapentin – Opioids: tramadol, oxycodone, hydrocodone, extended-release forms – Benzodiazepines: clonazepam – Iron supplementation Pharmacologic Treatment 3 of 3 • Refractory RLS symptoms – Change to a different dopamine agonist – Switch to an opioid or anticonvulsant – Add second medication, possibly with reduced agonist dose (e.g., add drug from another class) – Consider “drug holiday”: covered by opioid or different agonist – High-potency opioids for severe, resistant cases (e.g., methadone 5–40 mg/day) Special Populations • Pregnant patients (up to 20%) – Usually subsides after delivery; supplement with Fe and folic acid • Children – Sleep hygiene and caffeine avoidance first – Dopaminergic agents after; good response – Can help with ADHD sx • Secondary RLS – treat the problem Determining Response to Tx • Augmentation – Occurs with DA agents, especially with levodopa (~82%); 20-30% with others – Recognize and remove DA agent; treat with other agent • Best to use consistent rating scale (at each visit) – Two available…IRLSSG and Johns Hopkins RLS rating Scale IRLSSG Rating Scale Prognosis • In some patients, RLS sx may abate and disappear for years • In most patients, RLS sx never disappear • In many patients, RLS sx progress slowly over time (i.e. become more severe) • No long term studies of therapy (beyond one year) EB-Based Recommendations • RLS common (~10%) and underdiagnosed (~25%) – need to screen patients for sleep complaints and primary symptoms • Diagnosis is clinical based on 4 criteria • Secondary causes: Fe deficiency, pregnancy and ESRD – all treatable or self-limited • Treat based on frequency and severity of symptoms LOE – Tx - 2c; Dx - 2b; Prognosis - 2c; DDx - 2b EB-Based Recommendations • Dopamine agonists currently best agents for moderate to severe symptoms* • Intermittent or mild symptoms – lifestyle modifications +/- levodopa/carbidopa • Use rating scales to gauge response to therapy and symptom severity • Symptoms generally progressive *no long term studies; ropinirole, L-Dopa and pergolide best studied…from Bandolier ¿¿ Questions ??
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