Restless Legs Syndrome

RLS treatment involves suppression of abnormal sensations and leg movements and consolidation of sleep. Dopaminergic and sedative-hypnotic medications are prescribed commonly. In the last few years, dopamine agonists (DAs) have become the therapy of choice for the treatment of RLS, replacing levodopa/carbidopa as first-line agents. The DAs offer many advantages over levodopa/carbidopa, including longer half-lives to cover overnight symptoms, flexible dosing, and a reduced incidence of symptom augmentation. Up to 80% of patients who take levodopa/carbidopa eventually will experience symptom augmentation: RLS symptoms appear earlier in the day, previously unaffected body parts become involved, and higher doses of medication are required to control symptoms.45 Ropinirole (Requip) and pramipexole (Mirapex) are FDA approved for the treatment of RLS, and ropinirole is available in a sustained-release product.46,47 Gabapentin is an effective treatment for RLS, particu-

larly in patients with painful symptoms. BZDRAs such as temazepam, clonazepam, zolpidem, and zaleplon effectively reduce arousals associated with PLMS in patients with RLS.49 Their main benefit is derived from improving sleep continuity in patients with RLS, particularly as adjunct treatment with other pharmacologic therapies. Opioids are effective for some patients' RLS symptoms, with oxycodone, pro-poxyphene, hydrocodone, and codeine being used most frequently. For both BZDRAs and opioids, caution should be used in the elderly, in patients who snore and are at risk for sleep apnea, and in patients with a history of substance abuse. Low iron levels frequently exacerbate RLS symptoms. Iron supplementation should be prescribed in patients who are iron-deficient. Iron supplementation in patients with serum ferritin concentrations of less than 50 mcg/L improves RLS symptoms. Medications frequently used for RLS are shown in Table 41-3.

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