Articles

Restless Legs Syndrome

By Janna Gordon, R.Ph.

Are you having trouble sleeping due to a burning, crawling, or tightening sensation in your legs that is relieved by movement? Affecting more than 12 million people in the United States, Restless Legs Syndrome (RLS) is associated with older adults and is slightly more common in women. In some patients a chronic condition or medication may trigger the condition. While there is no known cause, it is more common in patients with low iron levels, kidney disease, chronic neurological conditions and pregnancy. One current theory on the cause of RLS involves a deficiency in a brain chemical called dopamine. RLS probably has a genetic basis in many cases. Diagnosis of RLS is challenging. RLS sufferers often have trouble working at a desk, concentrating on tasks, and many experience interrupted sleep.

After other diseases have been ruled out, a patient with a family history, worsening symptoms, and relief with leg movement is a key candidate for treatment. Currently, there is one prescription treatment, ropinirole (Requip®) approved in the United States for treatment of RLS. Initially approved for treatment of Parkinson's disease, it has been shown to help ease the symptoms of moderate to severe RLS. Other treatments recommended by the American Academy of Sleep Medicine include:

- Use of OTC pain relievers such as acetaminophen and non-steroidal anti-inflammatories.

- Supplements such as Vitamin E (800-1200mg per day); calcium (1500mg per day, along with 400iu of vitamin D for absorption), magnesium (750mg per day), or potassium may help some patients. In those who are deficient, taking adequate amounts of folic acid (400mcg) can help, especially in pregnancy.

- Iron supplements have been shown to provide significant RLS improvement in patients with low iron levels. Suggested dosing in adults is ferrous sulfate 300mg three times daily. Supplementation in patients with normal iron provides little improvement in symptoms.

- Dopaminergic agents, such as Levodopa increase the availability of the brain chemical dopamine and are the standard agents used for severe RLS. Levodopa combined with carbidopa improves the action of levodopa and reduces some of its side effects, particularly nausea. These drugs significantly reduce the number of limb movements per hour and improve the subjective quality of sleep. (Levodopa combinations are shown to be well tolerated and safe.)

- Benzodiazepines, such as clonazepam, commonly used for insomnia and anxiety, may be helpful for some patients with RLS that disrupts sleep. Benzodiazepines are associated with side effects, such as increased depression, trouble breathing, daytime drowsiness, memory loss, and should not be used during pregnancy or while breast feeding. They should not be mixed with alcohol use, or be taken with medications like cimetidine. In some patients treatment with benzodiazepines may produce withdrawal symptoms and rebound insomnia when discontinued.

- Narcotics are sometimes helpful in severely painful RLS and anti-seizure medications such as gabapentin, valproic acid derivatives, and carbamazepine, relax blood vessels and are being investigated for RLS.

- Selectin Serotonin Reuptake Inhibitors (SSRIs) increase serotonin levels in the brain have been shown in one study to reduce the symptoms of RLS in 58% of patients and to eliminate symptoms in 12% of patients. Conversely, this same study showed an increase in RLS symptoms in 12% of patients.

Finally, some may find relief by supplementing with L-Tyrosine (500-1000mg at bedtime). L-Tyrosine is an amino acid that is a precursor to the neurotransmitters norepinephrine and dopamine. Taking small amounts of vitamin B6 and vitamin C may help enhance absorption of amino acids. Food sources of L-Tyrosine include almonds, avocados, bananas, dairy products, lima beans, pumpkin and sesame seeds.

While there is currently no cure for RLS, it can be managed in many patients through proper diagnosis and appropriate treatment of symptoms.

- US Pharmacist, 2006
- University of Maryland Medical Center Website (http://www.umm.edu)
- www.rxlist.com