RLS and the new textbook

I was excited when, at the end of last week, the package containing my newly-purchased ‘SleepMultiMedia’ ‘textbook’ arrived. I was hoping that it was going to be like a conference on my laptop.

So this afternoon, I loaded it and opened it up.

Well, whoever put this together has done , aesthetically, a pretty good job. For a DOCTOR! Wow. I have powerpoint presentations that look better. I'm can't say I'm immediately rapt that we put off that overseas holiday to buy this resource....

However, as they say on Masterchef, it all comes down to how it tastes. What’s the content like?

So I decided to test it out and run through the Restless Legs Syndrome section. Having seen another patient with a history of back problems and very frequent Periodic Limb Movements in the clinic today it seemed opportune.

And it’s not too bad – although unfortunately there are some scripting errors I’ve come across already, as well as some spelling mistakes. Not what I really was after for the price.

Anyway, here’s my brief list of some important things about RLS:

- RLS can be IDIOPATHIC or SECONDARY (for example, to pregnancy)

- Over 40% of cases of idiopathic RLS are clearly HEREDITARY

- Most of our hypotheses about what causes RLS are based on which drugs we have (accidentally) found to be effective.

- Studies have not conclusively proven the role of DOPAMINE in development of RLS

- HOWEVER

- 90% of patients with idiopathic RLS have relief of symptoms with dopamine agonists - so we think it's important. (And I think that figure is an overestimate).

- Several studies have demonstrated low IRON in the central nervous system in primary/ idiopathic RLS

- Iron is a COFACTOR in the production of dopamine, which might be why it's lack is important

- RLS is associated with increased prevalence of HYPERTENSION and CARDIOVASCULAR DISEASE (Odds Ratios around 2.0, causation not proven)

- SSRIs (a class of antidepressants) cause RLS. Particularly VENLAFAXINE. This is CLINICALLY IMPORTANT.

- Frequency of IRON DEFICIENCY increases with age to be present in over 50% of patients who develop RLS over 65yrs of age

- DOPAMINE AGONISTS (such as pramipexole, ropinorole, cabergoline) are effective, and generally regarded as FIRST LINE treatment

- Dopamine agonists can MAKE THINGS WORSE or MAKE YOU SLEEPY. Which is not what we want.

- They can also make it difficult to control impulses – leading to COMPULSIVE BEHAVIOUR. Also not what we want

- Transdermal dopamine agonists, available elsewhere, are not available here as far as I am aware.

- OPIOIDS in general, in addition to TRAMADOL have been demonstrated to be of benefit in RLS

- BENZODIAZEPINES can improve sleep quality but have not been demonstrated to reduce leg movements

- GABAPENTIN works, but is said to be ‘reserved for those who fail the dopamine agonists’. I think this recommendation is health system specific. There are situations where GABAPENTIN would be appropriate to use as FIRST LINE TREATMENT – although it is not available on the PBS for this indication.

- IRON replacement is recommended if serum ferritin is less than 50mcg/L

- EXERCISE can help

How's that for a list. I've put a bit of colour to the points most relevant to my very recent practice.

Andrew