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
Showing posts with label restless legs syndrome. Show all posts
Showing posts with label restless legs syndrome. Show all posts
Monday, August 9, 2010
Wednesday, April 21, 2010
Restless Legs Syndrome
Frustration. Exhaustion. Inability to rest or sleep without twitchy or uncomfortable legs. An overwhelming urge to move affected limb.
Many people would not realize that these distinctive symptoms actually have a name and therefore go undiagnosed and untreated resulting in restlessness, difficulty in sleeping and daytime sleepiness.
Restless legs syndrome (RLS) is a central nervous disorder possibly with some genetic predisposition or related to an imbalance of dopamine in the brain. Dopamine is a brain chemical that affects movement and as levels normally drop at night this may explain why RSL is worse at this time. Iron is a significant factor in the production of dopamine which may account for the link between low iron levels and RLS symptoms.
RSL may be acerbated, but not caused by stress or psychiatric conditions.
As indicated RLS usually affects the legs particularly the calves but some people may experience symptoms in the upper legs, feet, hands or arms.
Primary RSL seems to have no cause. Those affected may have developed the condition during childhood and this may have been attributed to growing pains (or even ADHD). There is a tendency for the condition to increase with age with significant increase in severity often seen after age 50.
With secondary RLS there is usually a link to another condition. These include anaemia, kidney disease, Parkinson’s disease, pregnancy, thyroid problems, neurologic lesions, sleep apnoea or narcolepsy, and alcoholism.
There are certain medications that when taken may trigger or increase RSL symptoms, as may the withdrawal of some drugs.
Diagnosis is usually made on the basis of reported symptoms and medical history. The four established criteria are:
• Irresistable urge to move your legs along with uncomfortable sensations (may be described as creeping, crawling, pulling, tingling, itching, pain, burning)
• Symptoms commence or get worse at rest (sitting, lying down)
• Symptoms are partially relieved by activity (stretching, walking)
• Symptoms are worse at night
Blood tests or other investigations may be done to exclude other possible causes.
RSL doesn’t lead to other serious conditions but symptoms can become incapacitating for some sufferers especially excessive tiredness from sleep deprivation.
There is no cure for RLS but there are treatments available that can manage the condition and relieve discomfort. This may involve treatment of underlying conditions, lifestyle techniques which may require changes in daily behavior or habits, use of support groups and in severe cases transcutaneous electric nerve stimulation (TENS) for a short time at night may be of help. Medications are commonly prescribed but there is no one drug that works for everyone and they should always be used with caution as may have side effects or increase the symptoms of RSL. Usually the drugs prescribed are ones used for other conditions but have been found to be beneficial with symptoms of RLS. They may include dopaminergic agents, Benzodiazepines, non benzodiazepine sedatives, opiates and narcotics and hypertensive medications.
RSL may necessitate referral to a sleep specialist for further evaluation. This may require observation overnight at a sleep clinic where sleep can be monitored for periodic limb movements during sleep. However a diagnosis can usually be made without a sleep study.
Irene
Many people would not realize that these distinctive symptoms actually have a name and therefore go undiagnosed and untreated resulting in restlessness, difficulty in sleeping and daytime sleepiness.
Restless legs syndrome (RLS) is a central nervous disorder possibly with some genetic predisposition or related to an imbalance of dopamine in the brain. Dopamine is a brain chemical that affects movement and as levels normally drop at night this may explain why RSL is worse at this time. Iron is a significant factor in the production of dopamine which may account for the link between low iron levels and RLS symptoms.
RSL may be acerbated, but not caused by stress or psychiatric conditions.
As indicated RLS usually affects the legs particularly the calves but some people may experience symptoms in the upper legs, feet, hands or arms.
Primary RSL seems to have no cause. Those affected may have developed the condition during childhood and this may have been attributed to growing pains (or even ADHD). There is a tendency for the condition to increase with age with significant increase in severity often seen after age 50.
With secondary RLS there is usually a link to another condition. These include anaemia, kidney disease, Parkinson’s disease, pregnancy, thyroid problems, neurologic lesions, sleep apnoea or narcolepsy, and alcoholism.
There are certain medications that when taken may trigger or increase RSL symptoms, as may the withdrawal of some drugs.
Diagnosis is usually made on the basis of reported symptoms and medical history. The four established criteria are:
• Irresistable urge to move your legs along with uncomfortable sensations (may be described as creeping, crawling, pulling, tingling, itching, pain, burning)
• Symptoms commence or get worse at rest (sitting, lying down)
• Symptoms are partially relieved by activity (stretching, walking)
• Symptoms are worse at night
Blood tests or other investigations may be done to exclude other possible causes.
RSL doesn’t lead to other serious conditions but symptoms can become incapacitating for some sufferers especially excessive tiredness from sleep deprivation.
There is no cure for RLS but there are treatments available that can manage the condition and relieve discomfort. This may involve treatment of underlying conditions, lifestyle techniques which may require changes in daily behavior or habits, use of support groups and in severe cases transcutaneous electric nerve stimulation (TENS) for a short time at night may be of help. Medications are commonly prescribed but there is no one drug that works for everyone and they should always be used with caution as may have side effects or increase the symptoms of RSL. Usually the drugs prescribed are ones used for other conditions but have been found to be beneficial with symptoms of RLS. They may include dopaminergic agents, Benzodiazepines, non benzodiazepine sedatives, opiates and narcotics and hypertensive medications.
RSL may necessitate referral to a sleep specialist for further evaluation. This may require observation overnight at a sleep clinic where sleep can be monitored for periodic limb movements during sleep. However a diagnosis can usually be made without a sleep study.
Irene
Monday, February 1, 2010
Compulsive behaviours and restless legs syndrome
Restless legs syndrome (RLS) is a common neurological disorder, affecting up to 15% of people in our community. In up to 2.5% of our community the condition is so severe that quality of life is adversely affected.
The cause of this condition is unknown. Central dopaminergic pathways (dopamine is a neurotransmitter, a chemical carrying messages between nerves) have been implicated in this disorder, and ‘dopaminergic’ medications are first-line drugs when it comes to treating RLS. Dopaminergic neurological pathways beyond my understanding are also important in mechanisms of behavioural reward and reinforcement – ie you perform an action, it feels good so you do it again. Dopaminergic medications interfere with these pathways, and in some people this leads to reduced ability to control impulses towards the performance of personally destructive behaviours.
In the last five years or so, two relatively – new dopaminergic medications have become available in Australia for treatment of restless legs syndrome. The first of these, ropinirole, is available on private script only. The most recent, pramipexole, is available on the PBS for patients who score more than 21/40 on the International Restless Legs Syndrome Rating Scale. With the availability of pramipexole, previously used in the USA for treatment of RLS (and also used in Parkinson’s disease) has come increasing interest in the question of whether these medications really do cause reduced impulse control, and correspondingly increased compulsive behaviour. Is this true? Is it a problem?
A colleague of mine in at the Melbourne Sleep Disorders Centre has done some excellent, recent, local epidemiological work in this field. Similar work from the Mayo Clinic was published in Sleep journal last month. The findings were similar to those my colleague presented at the Australasian Sleep Association conference in Melbourne in October. They suggest that the phenomenon of reduced impulse control in patients with RLS on dopaminergic medications is real, and is a problem.
The recently - published article surveyed 100 consecutive patients with RLS who had been treated with dopaminergic medications. (Not all of these patients had been treated with pramipexole or ropinorole. Other medications included levodopa, bromocriptine, pergolide, cabergoline, rotigotine patch and apomorphine). They also surveyed 275 patients with obstructive sleep apneoa, as a control group, who had no symptoms of RLS. A smaller group of patients with RLS on no dopaminergics was also included (52 patients).
A variety of compulsive behaviours were screened for, using a mix of commonly used and validated screening tools (for compulsive gambling) and home-made questionnaires. Information was sought about compulsive gambling, shopping, eating, hypersexuality and ‘punding’. I had no idea about this last verb, but it refers to repetitive, complex, stereotypical but purposeless actions – for example grooming, cleaning, hording, operating technical equipment with no goal. A self – completed questionnaire was followed by a telephone interview to try to heighten the rigour of the process (and make it more specific for real problems).
The end result was that 17% of patients in the RLS group treated with dopaminergic agents displayed problems with impulse control. Only 6% of the OSA control group displayed similar behaviour. This 11% difference was statistically significant. In particular, compulsive shopping (9% vs 0.7%), gambling (5% vs 0.4%) and punding (7% vs1%) were behaviours where the striking discrepancy in prevalence was also statistically significant.
Twelve of the seventeen patients displaying difficulty with impulse control were taking pramipexole at the time of symptom onset, and fifteen of them had taken that medication at some time. Five were taking ropinorole at time of symptom onset.
These behaviours usually began several months after onset of therapy (mean of 9.5 months) . Their frequency may have been underreported because of study design (perhaps they should have surveyed husbands/wives/partners as well).
The case reports provided in the Sleep journal study serve to underline what is at stake here, and emphasise why it is important to aggressively screen patients on these medications for these bevhaviours – behaviours to which they will seldom readily confess. Sometimes stories communicate better than figures:
Case Report: A 47 yr old woman reported concerning behaviours after she had been taking pramipexole at 0.50mg daily for 6 months. She lost an estimated $5000 on purchases from the shopping channel (‘ugly clothes and jewelry that I didn’t even need’) and set her alarm clock for the early morning hours ‘because I just couldn’t miss a sale’. She had food binges, eating an entire pizza or a dozen donuts at one sitting ‘even though I wasn’t hungry’. Sometimes she would stay up ‘all hours of the night’ cross stitching. Finally, she reported ‘being more risky’ by performing sexual acts in public. Although present for almost 2 years, these behaviours resolved completely in 1 to 2 months after pramipexole was discontinued.
Case Report: A 59 yr old man is dealing with ongoing litigation related to inappropriate sexual behaviours involving the Internet that prompted police to raid his home, much to the shock of his wife and grandchildren. He gained more than 200pounds with food binges, his wife constantly returned unneeded purchases to the store, asnd he spent 10 to 12 hours per day on the computer in chat rooms, playing games and viewing pornography. All of the behaviours started within a year of his taking ropinirole, 4.0mg daily, and resolved quickly when he was taken off the medication.
Pramipexole can be tremendously effective in treatment of restless legs syndrome. The potential for associated problems with impulse control must not, however, be taken lightly.
The cause of this condition is unknown. Central dopaminergic pathways (dopamine is a neurotransmitter, a chemical carrying messages between nerves) have been implicated in this disorder, and ‘dopaminergic’ medications are first-line drugs when it comes to treating RLS. Dopaminergic neurological pathways beyond my understanding are also important in mechanisms of behavioural reward and reinforcement – ie you perform an action, it feels good so you do it again. Dopaminergic medications interfere with these pathways, and in some people this leads to reduced ability to control impulses towards the performance of personally destructive behaviours.
In the last five years or so, two relatively – new dopaminergic medications have become available in Australia for treatment of restless legs syndrome. The first of these, ropinirole, is available on private script only. The most recent, pramipexole, is available on the PBS for patients who score more than 21/40 on the International Restless Legs Syndrome Rating Scale. With the availability of pramipexole, previously used in the USA for treatment of RLS (and also used in Parkinson’s disease) has come increasing interest in the question of whether these medications really do cause reduced impulse control, and correspondingly increased compulsive behaviour. Is this true? Is it a problem?
A colleague of mine in at the Melbourne Sleep Disorders Centre has done some excellent, recent, local epidemiological work in this field. Similar work from the Mayo Clinic was published in Sleep journal last month. The findings were similar to those my colleague presented at the Australasian Sleep Association conference in Melbourne in October. They suggest that the phenomenon of reduced impulse control in patients with RLS on dopaminergic medications is real, and is a problem.
The recently - published article surveyed 100 consecutive patients with RLS who had been treated with dopaminergic medications. (Not all of these patients had been treated with pramipexole or ropinorole. Other medications included levodopa, bromocriptine, pergolide, cabergoline, rotigotine patch and apomorphine). They also surveyed 275 patients with obstructive sleep apneoa, as a control group, who had no symptoms of RLS. A smaller group of patients with RLS on no dopaminergics was also included (52 patients).
A variety of compulsive behaviours were screened for, using a mix of commonly used and validated screening tools (for compulsive gambling) and home-made questionnaires. Information was sought about compulsive gambling, shopping, eating, hypersexuality and ‘punding’. I had no idea about this last verb, but it refers to repetitive, complex, stereotypical but purposeless actions – for example grooming, cleaning, hording, operating technical equipment with no goal. A self – completed questionnaire was followed by a telephone interview to try to heighten the rigour of the process (and make it more specific for real problems).
The end result was that 17% of patients in the RLS group treated with dopaminergic agents displayed problems with impulse control. Only 6% of the OSA control group displayed similar behaviour. This 11% difference was statistically significant. In particular, compulsive shopping (9% vs 0.7%), gambling (5% vs 0.4%) and punding (7% vs1%) were behaviours where the striking discrepancy in prevalence was also statistically significant.
Twelve of the seventeen patients displaying difficulty with impulse control were taking pramipexole at the time of symptom onset, and fifteen of them had taken that medication at some time. Five were taking ropinorole at time of symptom onset.
These behaviours usually began several months after onset of therapy (mean of 9.5 months) . Their frequency may have been underreported because of study design (perhaps they should have surveyed husbands/wives/partners as well).
The case reports provided in the Sleep journal study serve to underline what is at stake here, and emphasise why it is important to aggressively screen patients on these medications for these bevhaviours – behaviours to which they will seldom readily confess. Sometimes stories communicate better than figures:
Case Report: A 47 yr old woman reported concerning behaviours after she had been taking pramipexole at 0.50mg daily for 6 months. She lost an estimated $5000 on purchases from the shopping channel (‘ugly clothes and jewelry that I didn’t even need’) and set her alarm clock for the early morning hours ‘because I just couldn’t miss a sale’. She had food binges, eating an entire pizza or a dozen donuts at one sitting ‘even though I wasn’t hungry’. Sometimes she would stay up ‘all hours of the night’ cross stitching. Finally, she reported ‘being more risky’ by performing sexual acts in public. Although present for almost 2 years, these behaviours resolved completely in 1 to 2 months after pramipexole was discontinued.
Case Report: A 59 yr old man is dealing with ongoing litigation related to inappropriate sexual behaviours involving the Internet that prompted police to raid his home, much to the shock of his wife and grandchildren. He gained more than 200pounds with food binges, his wife constantly returned unneeded purchases to the store, asnd he spent 10 to 12 hours per day on the computer in chat rooms, playing games and viewing pornography. All of the behaviours started within a year of his taking ropinirole, 4.0mg daily, and resolved quickly when he was taken off the medication.
Pramipexole can be tremendously effective in treatment of restless legs syndrome. The potential for associated problems with impulse control must not, however, be taken lightly.
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