Which drugs help in restless legs syndrome (RLS)?
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- Answered 30 May 2019 Conflict of interest declaration: None I found two guidelines from 2016 on RLS, one from the USA and one the UK. The American Academy of Neurology (https://n.neurology.org/content/87/24/2585.full) reports: “In moderate to severe primary RLS, clinicians should consider prescribing medication to reduce RLS symptoms. Strong evidence supports pramipexole, rotigotine, cabergoline, and gabapentin enacarbil use (Level A); moderate evidence supports ropinirole, pregabalin, and IV ferric carboxymaltose use (Level B). Clinicians may consider prescribing levodopa (Level C). Few head-to-head comparisons exist to suggest agents preferentially. Cabergoline is rarely used (cardiac valvulopathy risks). Augmentation risks with dopaminergic agents should be considered. When treating periodic limb movements of sleep, clinicians should consider prescribing ropinirole (Level A) or pramipexole, rotigotine, cabergoline, or pregabalin (Level B). For subjective sleep measures, clinicians should consider prescribing cabergoline or gabapentin enacarbil (Level A), or ropinirole, pramipexole, rotigotine, or pregabalin (Level B). For patients failing other treatments for RLS symptoms, clinicians may consider prescribing prolonged-release oxycodone/naloxone where available (Level C). In patients with RLS with ferritin ≤75 μg/L, clinicians should consider prescribing ferrous sulfate with vitamin C (Level B). When nonpharmacologic approaches are desired, clinicians should consider prescribing pneumatic compression (Level B) and may consider prescribing near-infrared spectroscopy or transcranial magnetic stimulation (Level C). Clinicians may consider prescribing vibrating pads to improve subjective sleep (Level C). In patients on hemodialysis with secondary RLS, clinicians should consider prescribing vitamin C and E supplementation (Level B) and may consider prescribing ropinirole, levodopa, or exercise (Level C).” The CKS guideline (https://cks.nice.org.uk/restless-legs-syndrome#!scenario) states: “Address any underlying cause that may have precipitated or exacerbated restless legs syndrome (RLS) that may need specific treatment” AND “What drugs should I consider to treat restless legs syndrome? First-line recommended drug options for people with frequent or daily symptoms are either: - A non-ergot dopamine agonist (pramipexole, ropinirole, or rotigotine), or - An alpha-2-delta ligand (pregabalin or gabapentin — both off-label indications).” AND “Factors that may influence the preferred choice of drug include: A dopamine-receptor agonist is generally preferred for people with severe symptoms, who are obese, have co-morbid depression, are at increased risk of falls, or have cognitive impairment. An alpha-2-delta ligand is generally preferred for people with severe sleep disturbance (disproportionate to other RLS symptoms), co-morbid insomnia or anxiety, RLS-related or co-morbid pain, or a history of an ICD. Consider rotigotine transdermal patch if the person has significant daytime symptoms as it has a long duration of action. A weak opioid (such as codeine), taken intermittently or regularly (depending on symptoms), is an alternative, particularly for people with painful symptoms of RLS. However, take into account the risk of opioid dependence.” Both guidelines give much greater detail including various warnings!
- Answered 15 Jun 2019 Conflict of interest declaration: I initially wrote the article Try this learning module (free to access) https://gpcpd.heiw.wales/clinical/restless-legs-syndrome/