Treatment for restless legs syndrome depends upon severity

Restless legs syndrome

There are a wide range of treatments for restless legs syndrome (RLS), ranging from getting up and moving to complex combinations of medications. Which strategy is used usually depends on how severe people’s symptoms are, how much impact the symptoms are having on sleep and quality of life, and other medical conditions people may have.

Non-drug strategies

For most people, who get RLS occasionally or only relatively mild symptoms, these strategies can work well. People tend to respond differently to different strategies, so if you find some of these don’t work so well for you, don’t be put off trying other strategies as you may find them effective.

Iron replacement: There is good evidence that low iron stores, measured by testing blood levels of ferritin, are a trigger for or can worsen RLS symptoms. If iron stores are low (ferritin <75mcg/L), replacing iron is a good starting point. This can be with tablets or an intravenous iron infusion. It’s important to remeasure iron levels after around 3 months to ensure iron stores / ferritin levels are >75mcg/L.

Magnesium: Supplements including magnesium are often promoted as reducing RLS symptoms or leg cramps. Magnesium can have an effect in reducing RLS symptoms, and I’ve seen a number of people who have had a good response to magnesium supplementation. However, there is very little data on magnesium, with one of the few studies in this area being published in 1998.

Avoiding caffeine: Some people find that caffeine makes their RLS symptoms worse. Caffeine is also found in chocolate, and I’ve seen a few people who have had big improvements in RLS since giving up chocolate in the evening.

Movement or pacing: RLS symptoms almost always get better with movement. Some people find that getting up from bed and walking around settles their symptoms enough to allow them to get off to sleep. People also tell me that walking barefoot on a cold floor like tiles or slate is helpful as the temperature also helps reduce symptoms.

Relaxis-pad

Relaxis

Massage: In some cultures, massage is a common treatment used for RLS, with family members massaging the legs of the person with RLS symptoms. Along these lines, the Relaxis device, approved for use in the United States, sits under the calves and vibrates reducing RLS symptoms. The intensity and pattern of vibration can be varied.

Mindfulness: There is good data for using mindfulness in both pain and insomnia, and with RLS having features of each, with leg pain and disturbed sleep, it would seem to make sense that mindfulness would be helpful in RLS. Based on this we conducted a pilot study in 10 people with severe RLS using mindfulness-based therapy, and showed mindfulness was effective at reducing RLS symptoms. All the people in our pilot study had very severe RLS, so the aim was to reduce symptoms rather than expect their symptoms to go away. The full results of this study should be published soon, and has already triggered other groups to look at using mindfulness in RLS in larger research studies.

Drug treatments

Paracetamol: Although there is not a lot of research looking at the role of paracetamol in treating RLS, it is something people often try, and many find helpful. Long-term use of low dose (e.g. 500-1000mg a night) paracetamol has been though to be safe, but recent research suggest that paracetamol may blunt emotions.

Alpha-2-delta calcium channel ligands (gabapentin / pregabalin): These drugs are now considered first line drug treatment for RLS in most international guidelines. There have been a number of studies showing both gabapentin (Neurontin) and pregabalin (Lyrica) are effective at reducing RLS symptoms. These drugs are generally also well tolerated without significant long-term side-effects, which is why they have replace dopamine agonists as first line treatment for RLS. A recent study in the New England Journal of Medicine showed that augmentation after 1 year of treatment was 2% with pregabalin versus 7.7% with pramipexole.

Dopamine agonists (pramipexole / ropinerole / rotigotine): Dopamine agonists, more commonly used as treatments for Parkinson’s Disease, have been the mainstay of RLS treatment for many years. They can be very effective at reducing RLS symptoms. However, in recent years, there has been recognition that this family of medications can induce impulse control disorders and result in problematic behaviours such as compulsive gambling, risk taking and promiscuity. It’s not clear how common this is, but in research we published in 2011 we identified 12 cases of impulse control disorders out of around 500 people who had taken dopamine agonists for RLS. Dopamine agonists can also result in augmentation and rebound, worsening symptoms over time.

Dopamine (levo-dopa): Levo-dopa was the first medication used to treat RLS and is still effective at reducing RLS symptoms. However, of all the medications used, it seems to have the greatest chance of inducing augmentation, particularly when used regularly. For this reason, I tend to use levo-dopa for people who only occasionally need to use a medication, during times when they are forced to sit still, such as at the movies or on plane flights, rather than using it on a daily basis.

Benzodiazepines (clonazepam): Clonazepam has also been used for many years for leg movements during sleep, both periodic limb movements and RLS. It’s now uncommon for clonazepam to be used by itself for RLS, and I’ll tend to use it in combination with other either gabapentin or dopamine agonists or both, in people with difficult to control RLS symptoms.

Opiates (codeine / fentanyl patches / methadone): Opiates are also generally used as an add-on treatment for people with severe and difficult to control RLS symptoms. They can be used in a tablet form such as codeine, or as patches (fentanyl), and can also be helpful to use for around 3 months to help manage augmentation symptoms in people who have developed augmentation or rebound on dopamine agonists.

Approach for different levels of severity

Which treatment options are used depends upon the severity of RLS symptoms. Though for everybody with RLS it is worth ensuring iron stores are good (ferritin >75mcg/L) and looking at other factors that might be exacerbating RLS such as medications. Most anti-depressants can exacerbate RLS symptoms, as can a range of other medications.

Mild or intermittent symptoms: If people are only getting symptoms occasionally and they aren’t that troubling, I’ll generally try to use non-drug strategies. However, if medications are needed, I’ll tend to use them on an as needed rather than a regular basis, and use levo-dopa or dopamine agonists such as pramipexole.

Moderate or symptoms most days: In this group, in addition to non-drug strategies, I’ll generally use medication on a regular basis and start with gabapentin or pregabalin. If people don’t get a good response then I will switch to a dopamine agonist such as pramipexole, ropinerole or rotigotine patch.

Severe with daily symptoms: For people with severe and very frequent symptoms that aren’t controled with a single medication, I’ll look at combining medications. Generally gabapentin together with a dopamine agonist and then even add in a benzodiazepine and opiate if needed. Some of my most severe patients are on 4 drugs – one from each class of medication used to treat RLS.

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