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Sleep Disorders

Restless Leg Syndrome

10/11/2005

Question:

I have been suffering several years with RLS symptoms and have used Sinemet and Klonopin but both have quit working for me. I have been on the FDA approved RLS drug, Requip for 3 months and just have not been happy with the results of this drug. The initial side effects (naseua and vomiting)of the drug are quite bad too. Other RLS sufferers I converse with are not happy with this drug either. I currently have been using Percocet so I can get to sleep at night along with Requip, but I have been told the Percocet can be highly addictive. I have been wondering about a TENS unit.

Do you know of any studies regarding RLS sufferers and TENS units? Also, I recently was hospitalized and I was given Ambien. This seemed to work great for my RLS. Is Ambien or Lunesta prescribed for RLS symptoms?

Answer:

Restless legs syndrome (RLS) is quite common, affecting roughly 10% of the adult population. The diagnosis of RLS truly rests upon the history with 4 key elements necessary to make a diagnosis. These are as follows:

Assuming you meet these criteria for the diagnosis, there are a number of treatment options available. The cause of RLS is unknown in most cases, though a search for potential underlying contributors is always worthwhile. Conditions or factors that may be associated with the onset or worsening of RLS include iron deficiency (this can be quite mild and still affect RLS), kidney failure, pregnancy, neuropathy (disease of the nerves), lack of folate or vitamin B12 or magnesium, excessive caffeine ingestion, and certain medications (such as tricyclic antidepressants and selective serotonin reuptake inhibitor antidepressants). If one of these factors is found, particularly one that may be reversible (such as iron deficiency), then addressing this as the initial treatment strategy may be effective and prevent the need for additional medications.

There are a number medications that can be used for the specific treatment of RLS, though at present roperinole (Requip) is the only drug with FDA approval. Roperinole comes from a class of drugs known as dopaminergic agonists, or drugs that mimic or help to release the chemical dopamine in the brain. Problems with this chemical are thought to be important in the underlying cause of RLS in most RLS patients. There are a number of drugs in this class aside from roperinole, including pramipaxole (Mirapex), pergolide (Permax) and caridopa-levodopa (Sinemet). In general, this class of agents is about 80-90% effective in controlling RLS symptoms and the medications are fairly well tolerated. Sinemet has the problematic side-effect of increasing RLS symptoms with long term usage and therefore is not routinely used these days.

While there is less data to support their use, other non-FDA approved medications commonly used for the treatment of RLS include the antiepileptic medications gabapentin (Neurontin) and carbamazepine (Tegretol), narcotics such as oxycodone (Percocet or Roxicet) and propoxyphene (Darvocet), sedatives such as clonazepam (Klonipin), and antihypertensive medications such as clonidine (Catapres). 

* Learn important new information concerning the FDA withdrawal of the medication Propoxyphene(Darvon, Darvocet)

Each of these medications has its own list of contraindications and side effects. In addition, some medications, such as the narcotics and sedatives, may create problems with tolerance (becoming adapted to the medication and needing higher and higher doses to get an effect) and addiction with long term use. Some individuals respond best to one class more than the others and often a "trial and error" approach is required to determine which medication(s) may be most effective for a given individual.

In your question, you asked about the use of zolpidem (Ambien) and eszopiclone (Lunesta) for the treatment of RLS. There are no current studies that have reported the effects of these medications on RLS. However, it is possible that they may have a similar effect to the sedatives mentioned above, namely that of helping individuals to fall asleep and "sleep through" the RLS symptoms.

You had also asked specifically about the use of TENS (transcutaneous electrical nerve stimulation) unit for treatment of RLS. I was unable to find any studies addressing this specific modality of treatment. However, other nonpharmacologic treatments that have been reported to be helpful by some individuals (though these are not well-studied) include hot bathes, leg massages, applying heat, applying ice packs and eliminating caffeine. Individuals have also reported that the use of aspirin, vitamin E or supplemental calcium may help to reduce symptoms, though these treatments have not been adequately studied either.

You should consider discussing your problems with your primary care physician. Specific factors in your history may be useful in tailoring a strategy that might work best for you. Referral to a Sleep Specialist in your area may also be helpful. If you would like further information about restless legs syndrome, sleep disorders or sleep itself, I recommend the American Academy of Sleep Medicine website. In addition to information about sleep medicine, the website also contains a list of accredited Sleep Centers and may help you to locate one nearest you. Another organization that may be very useful for those that suffer from RLS is the Restless Legs Syndrome Foundation. Their website has plenty of good information about RLS and is regularly updated. Good Luck!

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Response by:

Dennis   Auckley, MD Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University