The treatment of RLS

A strategy from:

Management of restless legs syndrome in primary care

Developed by RLS:UK

Non-pharmacological intervention

Good sleep hygiene and habits are helpful; advise patients to:

  • sleep in a quiet, comfortable and cool environment
  • Go to bed and wake at a regular hour (advise going to bed late and waking late)
  • Avoid taking diuretics or caffeine before bedtime

During an attack, patients may find benefit from:

  • Walking and stretching
  • Bathing in hot or cold water
  • Relaxation exercises (biofeedback or yoga)
  • Distracting the mind
  • Massaging affected limbs

Pharmacological treatment

The drugs used in RLS generally belong to the following classes:

A: Dopaminergic agents (Levodopa, dopamine agonists, amantadine; these drugs are also used in Parkinson's disease)

B: Anti-epilepsy drugs

C: Opoids

D: Benzodiazepines

E: Iron

F: Miscellaneous

A step-by-step approach to drug therapy may be useful:

Start treatment with a dopamine agonist (e.g., pramipexole, ropinirole) administered as a single evening dose
  • if intolerant to one agent, try an alternative dopamine agonist
  • this approach is a good long-term option
  • alleviates symptoms in at least 70% of patients
  • any augmentation is mild

Levodopa, taken at bedtime, may be used if patients are intolerant to dopamine agonists

  • 80-82% of patients treated will experience augmentation or rebound; therefore long-term use is limited
  • useful for intermittent RLS
Levodopa and dopamine agonsts:
  • use with caution in patients with angle-closure glaucoma, a history of malignant melanoma, cardiac disease or peptic ulcer disease
Levodopa is associated with gastrointestinal adverse events such as anorexia, nausea and vomiting
Patient age should be taken into account
Use medicine cautiously in pregnancy, RLS normally improves after parturition
Re-introduce dopamine agonists for patients in whom symptoms persist or begin to appear in the early morning (rebound phenomenon) or in the evening/daytime with spread to the upper limbs (augmentation)
  • Rotigotine transdermal patch may be particularly useful as it is administered once daily
Anti-epileptic drugs such as carbamazepine or gabapentin may be useful for refractory cases
  • these drugs work by inhibiting hyperactivity in the nervous system that may be related to the symptoms
  • Gabapentin is particularly useful for haemodialysis parients and for cases of painful RLS

Treatment strategies summarised

Dopaminergic drugs:

Pramipexole
  • Licensed for the treatment of moderate to severe RLS
  • Good for periodic limb movements
  • Low rates of augmentation
Dose range - 0.125-0.75 mg (salt) od
Ropinirole
  • Licensed for the treatment of moderate to severe RLS
  • Good for periodic limb movements
  • Low rates of augmentation

Dose range - 0.25-4 mg od

Rotigotine (transdermal patch)

  • Licensed for moderate to advanced RLS

Dose range - 1-3 mg/24hrs

Cabergoline

  • Related to cardiac valvulopathy
  • Needs monitoring with echocardiography
  • No longer recommended as first-line treatment

Dose range - 0.5-2 mg (single evening dose)

Pergolide

  • Related to cardiac valvulopathy
  • Needs monitoring with echocardiography
  • No longer recommended as first-line treatment

Dose range - 0.1-0.75 mg od/bid

Bromocriptine

  • Poor tolerance (preferably avoided)
  • No longer recommended as first-line treatment

Dose range - 7.5 mg (divided dose)

Apomorphine

  • Specialist monitoring required. Only recommended for severe RLS in Parkinson's disease

Dose range - 18-50 mg / 12hrs, overnight sc infusion

Levodopa DCI

  • Rebound/augmentation
  • Useful for intermittent RLS

Dose range - 100-600 mg evening or divided dose

Other drugs:

Gabapentin

  • Quick dose escalation
  • Useful second-line agent
  • Painful RLS
  • Useful in dialysis related RLS

Dose range - 300-2400 mg

Carbamazepine

  • Single/divided doses

Dose range - 100-600 mg

Oxycodone

  • Painful RLS

Dose range - 2.5-25 mg

Tramadol

  • Painful RLS and insomnia
Dose range - 50-100 mg

Clonazepam
  • Useful for associated insomnia

Dose range - 0.5-2 mg  evening dose

Triazolam

  • As above

Dose range - 0.125-0.25 mg

Nitrazepam

  • As above

Dose range - 2.5-10 mg

Clonodine

  • Uraemia

Dose range - 0.15-2 0.9mg

Iron sulphate

  • Iron deficiency (low ferritin levels)
Dose range - 200 mg tid oral

 

 
Call the RLS:UK/ESA HELPLINE: 01634 260483 - Line open Mondays and Thursdays: 9am - 11am
letters to RLS:UK/ESA, 42 Nursery Road, Rainham, Gillingham, Kent ME8 0BE