Restless Legs Syndrome - Lecture 5 - Dr. Scopelliti

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VASUpharm14
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Restless Legs Syndrome - Lecture 5 - Dr. Scopelliti
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2013-04-08 18:16:23
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M/S RLS Define the signs and symptoms of restless legs syndrome (RLS)  Understand the pathophysiology of RLS  Identify associated conditions related to the etiology of RLS  List the essential diagnostic criteria for RLS  Evaluate the pharmacological treatment options for RLS  Develop an appropriate treatment plan for a patient with RLS
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  1. Restless Legs syndrome def (RLS)
    unpleasant sensations in the legs accompanied by involuntary urges to move them. Sometime the arms or other parts of the body are also affected.
  2. RLS prevalence
    • 5-15%
    • women
  3. Primary RLS (2)
    • 1. genetic
    • 2. age
  4. Secondary RLS (5)
    • 1. Iron Deficiency
    • 2. preggos
    • 3. ESRD
    • 4. Peripheral neuropathy
    • 5. Drug-induced
  5. drug-induced CAUSES of RLS (4)
    • 1. dopamine-blocking agents (AP, Antiemetics - metoclopramide)
    • 2. Antidepressants (TCAs, SSRI's)
    • 3. Antihistamines (diphenhydramine)
    • 4. Common stimulants/depressants (caffeine, alcohol, nicotine)
  6. genetic link - familial RLS
    • 3-5x first degree relatives
    • >50% have affected family members
  7. dopamine and RLS
    • normal: affects basal ganglia motor loop
    • regulates how brain controls MOVEMENT
    • dysfunction (dopamine in brain): decreased D2 receptor binding and decreased dopaminergic transmission
  8. clinical presentation of RLS (4)
    • "creepy, crawly" in lower legs
    • 1. bilateral/symmetrical
    • 2. occurs at rest 
    • 3. irresistible urge to move - relieve with movement
    • 4. timing - late evening "night-walker's syndrome"
  9. t/f pain is always present
    false. pain MAY be present
  10. t/f no objective labs for RLS
    • true. rule out secondary causes
    • physical exam usually NORMAL
  11. secondary causes RLS
    • serum ferritin, total iron-binding capacity
    • preggo?
    • serum creatinine, BUN
  12. diagnostic criteria for RLS (4)
    • 1. urge to move b/c unpleasant sensations in legs
    • 2. urge to move worsens at rest or inactivity
    • 3. urge to move relieved by movement
    • 4. urge to move worse at night/evening
  13. Tx primary cause: iron deficiency anemia
    • serum ferritin < 20 mcg/mL
    • <45-50 mcg/mL - associated with increased RLS severity
    • so treat with oral iron supplementation
    • - common: ferrous sulfate 325 mg + vitamin 250-500 mg TID
  14. GOAL for treating iron deficiency anemia
    • ferritin >50 mcg/mL
    • Tstat > 20%
  15. nonpharm for RLS (4)
    • 1. behavioral
    •  - d/c aggravating factors: meds, alcohol, nicotine, caffeine
    •  - improve sleep hygiene
    • 2. exercises
    • 3. massages
    • 4. hot baths
  16. 4 pharmacological tx for RLS
    • 1. Dopaminergics
    • 2. anticonvulsants
    • 3. benzodiazepines
    • 4. opioids
  17. first-line therapy for RLS
    • dopaminergic
    • -mild or intermittent (not responsive to nonpharm)
    • -mode-severe (persistant nightly sx)
  18. augmentation of dopaminergic agents for RLS
    • progressive worsening after initial improvement
    • -6-18 months after initiation
    • d/c meds and substitute
  19. dopaminergic for RLS: Sinemet (carbidopa/levodopa)
    • place in therapy: INTERMITTENT USE
    • levodopa: increases dopamine levels in the brain
    • carbidopa: decarboxylase inhibitor, inhibits peripheral breakdown of levodopa, doesn't cross BBB
    • administer: orally PRN or scheduled
  20. AE: Sinemet (Carbidopa/levodopa)
    • N/D, dyspepsia, orthostatic HYPO tension, h/a
    • augmentation - highest 50-85%
    • PK: short-half-life dose more times
  21. dopaminergic for RLS: pramipexole (Mirapex), ropinirole (Requip)
    • FDA approved
    • place in therapy: Mode/severe sx. FIRST LINE IN PERSISTENT/NIGHTLY Sx
    • MOA: nonergot dopamine agonists
    • -bind to dopamine receptors, producing dopamine-like effects
  22. dosage/administration pramipexole (Mirapex), ropinirole (Requip)
    dose bedtime
  23. AE: pramipexole (Mirapex), Ropinirole (Requip)
    • nausea, somnolence, HYPO tension, dizziness, pedal edema (dose dependent)
    • augmentation - less likely 20-30%
    • PK: longer half-life than levodopa
  24. dopaminergic for RLS: rotigotine transdermal system (Neupro)
    • place in therapy: moderate/severe primary RLS
    • FDA approved
  25. AE: rotigotine (Neupro)
    application site reactions, nausea, somnolence, h/a
  26. anticonvulsants for RLS: Gabapentin enacarbil (Horizant)
    • place in therapy: moderate to severe - adults
    • FIRST-LINE: painful, combo with peripheral neuropathy
    • FDA approved
    • PRODRUG to gabapentin
    • longer acting
    • better absorbed, costly, no evidence though
  27. Gabapentin enacarbil (Horizant) administration
    • NOT 1:1 with regular gabapentin (100-300 mg) so no sub
    • oral 600 mg QD (no increase needed)
    • RENALLY ADJUSTED
  28. AE: gabapentin enacarbil (Horizant)
    • somnolence, dizziness
    • watch out for elderly, renal impairment
  29. benzodiazepines for RLS:
    • place in therapy: alt tx to levodopa with mild-intermittent sx, add on in severe, poor sleep
    • mixed results
    • improve sleep
    • clonazepam 0.5-2 mg (long half-life)
    • administration: oral before bedtime
  30. AE: benzodiazepines
    sedation, daytime somnolence
  31. opioids for RLS: tramadol, propoxyphene, hydrocodone, oxycodone, codeine, methadone
    • place in therapy: painful/refractory RLS, relieve pain, motor restlessness, sleep disturbances
    • administration: prior to bedtime
    • QD - TID on timing of sx
  32. AE: opioids
    respiratory depression, sedation, constipation

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