Restless legs syndrome: Diagnostic time-savers, Tx tips

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Applied Evidence

Restless legs syndrome: Diagnostic time-savers, Tx tips

J Fam Pract. 2009 August;58(8):415-423

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References

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Gabapentin also has fewer side effects and drug interactions than other anticonvulsants. (Both carbamazepine and valproate have also been studied for the treatment of RLS symptoms, but at best, provided only modest improvements.)

Opioids have long been recognized as an effective treatment for RLS, but their use is limited by the potential for abuse.⁶ In a double-blind crossover trial, 10 of 11 patients preferred opioids over placebo, and significantly more rated their leg sensations as mild after 2 weeks of treatment with opioids (NNT=2). The most common side effects were constipation and sedation (NNH=3).^17,29

Many patients obtain symptom relief from low-potency opioids such as codeine, taken at bedtime, and there appears to be a lower abuse potential when bedtime-only dosing is used. However, higher-potency opioids may be necessary for patients with refractory RLS.¹⁷

One study did show an increase in symptoms of sleep apnea in RLS patients treated with opioids. If you suspect sleep apnea in an RLS patient taking opioids, provide a referral for a polysomnography evaluation.³⁰

FAST TRACK

If you suspect sleep apnea in a patient taking opioids for RLS, provide a referral for polysomnography.

Benzodiazepines. There is limited evidence to support the use of clonazepam in the treatment of RLS. Although a prospective controlled study found clonazepam to be no more effective than placebo in RLS treatment,³¹ clonazepam has been shown to be an effective treatment in patients with PLMS.³² Because of the association between these 2 movement disorders, clonazepam is considered an option to use alone or as adjunctive therapy in patients with RLS.^2,7

CASE STUDY: Grace’s diagnosis and treatment

In addition to having the 4 essential criteria for RLS, Grace reported sleep disturbances and periodic leg movements—2 additional features that are common to RLS. She also had low serum iron levels; however, her iron deficiency was related to her gastric bypass, and she was unable to tolerate iron therapy. We started her on a low dose of pramipexole, and she had a significant—and rapid—improvement in symptoms. When we last saw her, she reported that she usually slept through the night and that her leg movements had diminished so much that her husband no longer found it necessary to sleep in a separate bed.

Correspondence
Darlene E. Moyer, MD, Scottsdale Healthcare Family Medicine Residency Program, University of Arizona School of Medicine, 7301 East 2nd Street, Suite 210, Scottsdale, AZ 85251; darlene.moyer@gmail.com