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Restless Legs Syndrome
Pamela Hamilton-Stubbs, BSN, M.D. Director  Sleep Clinic for Children and Adults Richmond, Virginia Assistant Clinical Pro...
Objectives <ul><li>RLS diagnostic criteria for adults and children </li></ul><ul><li>The evaluation RLS </li></ul><ul><li>...
<ul><li>“ It doesn’t matter that there isn’t a cure.  At least it has a name. I’ve been putting up with this for twenty ye...
Case # 1 <ul><li>RB is a 51 year old Caucasian male with a history of bilateral leg discomfort described as “heebie jeebie...
Definition of RLS <ul><li>Restless legs syndrome is a sensorimotor disorder characterized by an urge to move the legs asso...
Presentation of RLS <ul><li>RLS can be unilateral or bilateral </li></ul><ul><li>Affect the ankle, knee or entire limb </l...
Did you know? <ul><li>RLS affects 3-10% of the general population </li></ul><ul><li>Treatment is usually sought after 40 y...
Clemens et.al Neurology 2006:67 Pathology is unknown but research is focused on the  dopaminergic diencephalo-spinal pathway
<ul><li>Symptomatic response to dopamine </li></ul><ul><li>Symptomatic response to iron </li></ul><ul><li>Anatomic changes...
Pathology  <ul><li>Tyrosine   DOPA   Dopamine </li></ul><ul><li>Fe </li></ul><ul><li>Tyrosine hydroxylase </li></ul>
Etiology <ul><li>Unknown </li></ul><ul><li>Two types of RLS </li></ul><ul><ul><li>Primary </li></ul></ul><ul><ul><li>Sympt...
<ul><li>“  I feel so guilty.  I don’t have it but my children do.” </li></ul>Mother of a RLS support group member
Primary RLS <ul><li>Thought to be genetic </li></ul><ul><li>Forty to 65% of people with RLS report a positive family histo...
Primary RLS <ul><li>Occurs independent of other disorders </li></ul><ul><li>Can be exacerbated by other factors </li></ul>...
Mode of inheritance <ul><li>Not clear but  has been described as  </li></ul><ul><ul><li>Autosomal dominant  </li></ul></ul...
Symptomatic RLS <ul><li>RLS precipitated by other medical disorders and resolves when the precipitating disorder is treate...
Disorders Precipitating Symptomatic RLS <ul><li>Iron deficiency anemia and all causes precipitating iron deficiency </li><...
Differential Diagnosis Of RLS In Adults <ul><li>Positional Discomfort </li></ul><ul><li>Akathisia </li></ul><ul><li>Period...
Differential diagnosis in Children <ul><li>Growing pains </li></ul><ul><li>Motor Tics </li></ul><ul><li>ADHD </li></ul><ul...
Essential Diagnostic Criteria <ul><li>Patients greater than 12 years of age </li></ul><ul><li>Urge to move the legs usuall...
Diagnostic Criteria <ul><li>Patients 2 to 12 years of age </li></ul><ul><li>Child meets all 4 essential diagnostic criteri...
Pediatric Diagnostic Criteria Continued <ul><li>Child meets all 4 essential diagnostic criteria but does not describe symp...
Evaluation
Sleep History
Diet History
Dietary triggers
Medical History
Family History
Sleep Journals <ul><li>http://www.rls.org </li></ul>
<ul><li>Laboratory </li></ul><ul><ul><li>Serum iron  </li></ul></ul><ul><ul><li>ferritin levels </li></ul></ul>
Treatment <ul><li>Depends upon the frequency and severity of symptoms </li></ul>
Categories  <ul><li>1) intermittent symptoms  </li></ul><ul><li>2) daily symptoms.  </li></ul><ul><li>3) symptoms refracto...
Symptomatic RLS <ul><li>Treatment of Symptomatic RLS is the same for adults and children </li></ul><ul><li>Treat the prima...
Persistent symptomatic RLS <ul><li>When symptomatic RLS does not resolve by treating the primary disorder or the primary d...
Nonpharmacologic treatments <ul><li>Should be used with all patients </li></ul><ul><li>Nonpharmacologic treatments may </l...
Nonpharmacologic <ul><ul><li>Diet </li></ul></ul><ul><ul><li>Eliminate precipitating factors </li></ul></ul><ul><ul><li>Ex...
Sleep Hygiene <ul><li>Establish a regular bed time </li></ul><ul><li>Only use the bedroom for sleep and intimacy </li></ul...
Mental distraction <ul><li>There are reports in the literature that engaging in some activities such as playing a piano, R...
<ul><li>“ My legs are killing me! But they never seem to bother me when I’m playing poker, especially if I’m winning” </li...
Pharmacologic Treatment <ul><li>Only the following medications are FDA approved for the treatment of RLS </li></ul><ul><li...
Pharmacologic Treatment <ul><li>Off Label: </li></ul><ul><li>Benzodiazepines </li></ul><ul><li>Opioids </li></ul><ul><li>A...
Pharmacologic Treatment <ul><li>Adults </li></ul><ul><ul><li>Can use all medication options </li></ul></ul><ul><ul><li>Chi...
Pharmacologic Treatment <ul><li>Dopaminergics </li></ul><ul><li>Sedatives </li></ul><ul><li>Benzodiazepines </li></ul><ul>...
Dopaminergics <ul><li>Levodopa /carbidopa 100- 200 mg </li></ul><ul><li>Cabergoline 0.5 – 4 mg </li></ul><ul><li>Ropinirol...
Pramipexole <ul><li>Supplied as:  0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 1.5mg </li></ul><ul><li>Administration </li></ul><ul><u...
Ropinirole <ul><li>Supplied as: 0.25 mg, 0.5 mg,1mg, 2 mg, 3 mg, 4mg, 5 mg </li></ul><ul><li>Titration schedule </li></ul>...
Medication side effect <ul><li>Dopaminergics </li></ul><ul><ul><li>Augmentation </li></ul></ul><ul><ul><li>Rebound  </li><...
Sedatives <ul><li>Shorting acting agents are used to treat sleep onset insomnia  </li></ul><ul><li>Intermediate acting age...
Sedatives <ul><li>Short acting  </li></ul><ul><li>Triazolam 0.125 – 0.5 mg </li></ul><ul><li>Zolpidem 5 – 10 mg </li></ul>...
Benzodiazepines <ul><li>Clonazepam 0.5 – 2 mg </li></ul><ul><li>Flunazepam 15 – 60 mg </li></ul>
Anticonvulsants <ul><li>Gabapentin 300 – 2,700 mg </li></ul>
Opioids <ul><li>Codeine (compounded) 15-120 mg </li></ul><ul><li>Propoxyphene HCL 65 – 520 mg </li></ul><ul><li>Oxycodone ...
Pharmacologic Management of  Intermittent RLS <ul><ul><li>Levodopa/Carbidopa  </li></ul></ul><ul><ul><li>Opioids: codeine,...
Pharmacologic Management of Daily RLS <ul><ul><li>Dopamine agonists </li></ul></ul><ul><ul><li>Anticonvulsants </li></ul><...
Refractory RLS <ul><li>Change to a different dopamine agonist </li></ul><ul><li>Switch to an opioid or anticonvulsant </li...
Prognosis <ul><li>Primary RLS is  </li></ul><ul><ul><li>Life long disorder </li></ul></ul><ul><ul><li>Symptom severity wax...
Summary <ul><li>Adult </li></ul><ul><li>Type of RLS </li></ul><ul><li>Primary or Secondary </li></ul><ul><li>Diagnostic Cr...
<ul><li>“ Sometimes I wish I could cut my legs off”. </li></ul><ul><li>Patient with RLS </li></ul>
Acknowledgements <ul><li>All thanks and glory to God </li></ul><ul><li>I also want to thank my family,  </li></ul><ul><li>...
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Restless Legs Syndrome 2007 Sleep Symposium Nma Folder

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Transcript of "Restless Legs Syndrome 2007 Sleep Symposium Nma Folder"

  1. 1. Restless Legs Syndrome
  2. 2. Pamela Hamilton-Stubbs, BSN, M.D. Director Sleep Clinic for Children and Adults Richmond, Virginia Assistant Clinical Professor Virginia Commonwealth University Medical College of Virginia
  3. 3. Objectives <ul><li>RLS diagnostic criteria for adults and children </li></ul><ul><li>The evaluation RLS </li></ul><ul><li>Nonpharmacologic and pharmacologic treatments for RLS </li></ul>Participants will become familiar with
  4. 4. <ul><li>“ It doesn’t matter that there isn’t a cure. At least it has a name. I’ve been putting up with this for twenty years.” </li></ul>Husband of a patient with RLS
  5. 5. Case # 1 <ul><li>RB is a 51 year old Caucasian male with a history of bilateral leg discomfort described as “heebie jeebies deep inside my legs. I have to get up and move”. Symptoms started approximately 10 years ago. Symptoms are more severe at night and after long periods of inactivity. Walking relieves symptoms temporarily. </li></ul>
  6. 6. Definition of RLS <ul><li>Restless legs syndrome is a sensorimotor disorder characterized by an urge to move the legs associated with annoying sensations including pain. </li></ul>
  7. 7. Presentation of RLS <ul><li>RLS can be unilateral or bilateral </li></ul><ul><li>Affect the ankle, knee or entire limb </li></ul><ul><li>With progression it may affect other parts of the body such as the arms, trunk or face </li></ul>
  8. 8. Did you know? <ul><li>RLS affects 3-10% of the general population </li></ul><ul><li>Treatment is usually sought after 40 years of age </li></ul><ul><li>RLS occurs 1.5-2 times more often in women than men </li></ul><ul><li>RLS affects </li></ul><ul><ul><li>1.9% Children 8 – 11 years </li></ul></ul><ul><ul><li>2 % Children 12 - 17 </li></ul></ul>
  9. 9. Clemens et.al Neurology 2006:67 Pathology is unknown but research is focused on the dopaminergic diencephalo-spinal pathway
  10. 10. <ul><li>Symptomatic response to dopamine </li></ul><ul><li>Symptomatic response to iron </li></ul><ul><li>Anatomic changes at autopsy </li></ul>Why the dopaminergic diencephalo-spinal pathway?
  11. 11. Pathology <ul><li>Tyrosine DOPA Dopamine </li></ul><ul><li>Fe </li></ul><ul><li>Tyrosine hydroxylase </li></ul>
  12. 12. Etiology <ul><li>Unknown </li></ul><ul><li>Two types of RLS </li></ul><ul><ul><li>Primary </li></ul></ul><ul><ul><li>Symptomatic </li></ul></ul>
  13. 13. <ul><li>“ I feel so guilty. I don’t have it but my children do.” </li></ul>Mother of a RLS support group member
  14. 14. Primary RLS <ul><li>Thought to be genetic </li></ul><ul><li>Forty to 65% of people with RLS report a positive family history. </li></ul><ul><li>3-5 times greater risk of developing RLS in people with a relative with RLS </li></ul><ul><li>Loci on chromosomes 2q, 12, 14, 9, 20 and 6 have been implicated but no disease-causing gene has been identified. </li></ul>
  15. 15. Primary RLS <ul><li>Occurs independent of other disorders </li></ul><ul><li>Can be exacerbated by other factors </li></ul><ul><li>People less than 35 years of age are more likely to have primary RLS </li></ul>
  16. 16. Mode of inheritance <ul><li>Not clear but has been described as </li></ul><ul><ul><li>Autosomal dominant </li></ul></ul><ul><ul><li>recessive with a pseudo-dominant pattern </li></ul></ul><ul><ul><li>A sporadic form is also described </li></ul></ul>
  17. 17. Symptomatic RLS <ul><li>RLS precipitated by other medical disorders and resolves when the precipitating disorder is treated </li></ul>
  18. 18. Disorders Precipitating Symptomatic RLS <ul><li>Iron deficiency anemia and all causes precipitating iron deficiency </li></ul><ul><li>Diabetes </li></ul><ul><li>Peripheral neuropathy </li></ul><ul><li>Radiculopathy, </li></ul><ul><li>Renal failure, </li></ul><ul><li>Rheumatoid arthritis, </li></ul><ul><li>Fibromyalgia </li></ul><ul><li>Medications </li></ul><ul><li>Dietary factors: caffeine, alcohol, tobacco </li></ul>
  19. 19. Differential Diagnosis Of RLS In Adults <ul><li>Positional Discomfort </li></ul><ul><li>Akathisia </li></ul><ul><li>Periodic Limb Movements </li></ul><ul><li>Sleep related leg cramps </li></ul><ul><li>Arthritis </li></ul><ul><li>Injury </li></ul><ul><li>Neuropathy </li></ul><ul><li>Vascular disease </li></ul>
  20. 20. Differential diagnosis in Children <ul><li>Growing pains </li></ul><ul><li>Motor Tics </li></ul><ul><li>ADHD </li></ul><ul><li>Muscle pain </li></ul><ul><li>Leg cramps </li></ul><ul><li>Osgood-Schlatter’s Disease </li></ul><ul><li>Arthralgia </li></ul><ul><li>Akathisia </li></ul>
  21. 21. Essential Diagnostic Criteria <ul><li>Patients greater than 12 years of age </li></ul><ul><li>Urge to move the legs usually accompanied by annoying sensations </li></ul><ul><li>Periods of rest/inactivity increase the symptoms </li></ul><ul><li>Symptoms are relieved partially or totally by movement </li></ul><ul><li>Symptoms are worse or occur only during the evening or night </li></ul>
  22. 22. Diagnostic Criteria <ul><li>Patients 2 to 12 years of age </li></ul><ul><li>Child meets all 4 essential diagnostic criteria and describes symptoms in his/her own words </li></ul><ul><ul><ul><ul><li>Or </li></ul></ul></ul></ul>
  23. 23. Pediatric Diagnostic Criteria Continued <ul><li>Child meets all 4 essential diagnostic criteria but does not describe symptoms in his/her own words </li></ul><ul><li>And has at least one of the following </li></ul><ul><ul><li>Sleep disturbance for age </li></ul></ul><ul><ul><li>Biological parent or sibling with RLS </li></ul></ul><ul><ul><li>Polysomnogram documents periodic limb movements </li></ul></ul>
  24. 24. Evaluation
  25. 25. Sleep History
  26. 26. Diet History
  27. 27. Dietary triggers
  28. 28. Medical History
  29. 29. Family History
  30. 30. Sleep Journals <ul><li>http://www.rls.org </li></ul>
  31. 31. <ul><li>Laboratory </li></ul><ul><ul><li>Serum iron </li></ul></ul><ul><ul><li>ferritin levels </li></ul></ul>
  32. 32. Treatment <ul><li>Depends upon the frequency and severity of symptoms </li></ul>
  33. 33. Categories <ul><li>1) intermittent symptoms </li></ul><ul><li>2) daily symptoms. </li></ul><ul><li>3) symptoms refractory to standard medical treatment </li></ul>
  34. 34. Symptomatic RLS <ul><li>Treatment of Symptomatic RLS is the same for adults and children </li></ul><ul><li>Treat the primary disorder and RLS will improve or resolve. </li></ul>
  35. 35. Persistent symptomatic RLS <ul><li>When symptomatic RLS does not resolve by treating the primary disorder or the primary disorder cannot be cured, symptomatic RLS is treated the same as primary RLS </li></ul>
  36. 36. Nonpharmacologic treatments <ul><li>Should be used with all patients </li></ul><ul><li>Nonpharmacologic treatments may </li></ul><ul><ul><li>Eliminate symptoms in some patients </li></ul></ul><ul><ul><li>reduce symptoms in some patients </li></ul></ul><ul><ul><li>not affect RLS symptoms </li></ul></ul>
  37. 37. Nonpharmacologic <ul><ul><li>Diet </li></ul></ul><ul><ul><li>Eliminate precipitating factors </li></ul></ul><ul><ul><li>Exercise in moderation </li></ul></ul><ul><ul><li>Hot/cold soaks </li></ul></ul><ul><ul><li>Sleep hygiene </li></ul></ul><ul><ul><li>Change bedtime </li></ul></ul><ul><ul><li>Mental distraction </li></ul></ul><ul><ul><li>Support group </li></ul></ul>
  38. 38. Sleep Hygiene <ul><li>Establish a regular bed time </li></ul><ul><li>Only use the bedroom for sleep and intimacy </li></ul><ul><li>Limit time in bed to time asleep </li></ul><ul><li>Create a comfortable environment </li></ul><ul><ul><li>Slightly cool room </li></ul></ul><ul><ul><li>Good mattress </li></ul></ul><ul><ul><li>Clutter free room </li></ul></ul>
  39. 39. Mental distraction <ul><li>There are reports in the literature that engaging in some activities such as playing a piano, RLS symptoms will decrease. </li></ul>
  40. 40. <ul><li>“ My legs are killing me! But they never seem to bother me when I’m playing poker, especially if I’m winning” </li></ul>92 year old patient with RLS
  41. 41. Pharmacologic Treatment <ul><li>Only the following medications are FDA approved for the treatment of RLS </li></ul><ul><li>Ropinorole </li></ul><ul><li>Pramipexole </li></ul><ul><li>Rotigotine (RLS in Parkinson disease) </li></ul>
  42. 42. Pharmacologic Treatment <ul><li>Off Label: </li></ul><ul><li>Benzodiazepines </li></ul><ul><li>Opioids </li></ul><ul><li>Anticonvulsants </li></ul>
  43. 43. Pharmacologic Treatment <ul><li>Adults </li></ul><ul><ul><li>Can use all medication options </li></ul></ul><ul><ul><li>Children </li></ul></ul><ul><ul><li>Avoid narcotics </li></ul></ul>
  44. 44. Pharmacologic Treatment <ul><li>Dopaminergics </li></ul><ul><li>Sedatives </li></ul><ul><li>Benzodiazepines </li></ul><ul><li>Opioids </li></ul><ul><li>Anticonvulsants </li></ul>
  45. 45. Dopaminergics <ul><li>Levodopa /carbidopa 100- 200 mg </li></ul><ul><li>Cabergoline 0.5 – 4 mg </li></ul><ul><li>Ropinirole 0.25- 6 mg </li></ul><ul><li>Pramipexole 0.125 – 1 mg </li></ul>
  46. 46. Pramipexole <ul><li>Supplied as: 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 1.5mg </li></ul><ul><li>Administration </li></ul><ul><ul><li>Start with 0.125 mg 2-3 hours before bedtime. </li></ul></ul><ul><ul><li>Increase by 0.125mg every 4-7 days as needed </li></ul></ul><ul><ul><li>Maximum evidenced based effective dose is 0.5 mg </li></ul></ul>
  47. 47. Ropinirole <ul><li>Supplied as: 0.25 mg, 0.5 mg,1mg, 2 mg, 3 mg, 4mg, 5 mg </li></ul><ul><li>Titration schedule </li></ul><ul><ul><li>Day 1 & 2 0.25 mg </li></ul></ul><ul><ul><li>Days 3 – 7 0.5 mg </li></ul></ul><ul><ul><li>Can increase weekly by 0.5mg to a maximum dose of 4 mg </li></ul></ul>
  48. 48. Medication side effect <ul><li>Dopaminergics </li></ul><ul><ul><li>Augmentation </li></ul></ul><ul><ul><li>Rebound </li></ul></ul><ul><ul><li>Sleep attacks </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Headache </li></ul></ul>
  49. 49. Sedatives <ul><li>Shorting acting agents are used to treat sleep onset insomnia </li></ul><ul><li>Intermediate acting agents are used to treat sleep maintenance insomnia and early morning awakenings </li></ul>
  50. 50. Sedatives <ul><li>Short acting </li></ul><ul><li>Triazolam 0.125 – 0.5 mg </li></ul><ul><li>Zolpidem 5 – 10 mg </li></ul><ul><li>Zaleplon 5 – 10 mg </li></ul><ul><li>Intermediate acting </li></ul><ul><li>Temazepam 15 – 30 mg </li></ul><ul><li>Eszopiclone 1-3 mg </li></ul>
  51. 51. Benzodiazepines <ul><li>Clonazepam 0.5 – 2 mg </li></ul><ul><li>Flunazepam 15 – 60 mg </li></ul>
  52. 52. Anticonvulsants <ul><li>Gabapentin 300 – 2,700 mg </li></ul>
  53. 53. Opioids <ul><li>Codeine (compounded) 15-120 mg </li></ul><ul><li>Propoxyphene HCL 65 – 520 mg </li></ul><ul><li>Oxycodone 5 – 20 mg </li></ul><ul><li>Hydrocodone 5 – 20 mg </li></ul><ul><li>Tramadol 50 – 400 mg </li></ul><ul><li>Methadone 5- 40 mg </li></ul>
  54. 54. Pharmacologic Management of Intermittent RLS <ul><ul><li>Levodopa/Carbidopa </li></ul></ul><ul><ul><li>Opioids: codeine, propoxyphene, tramadol, hydrocodone,oxycodone </li></ul></ul><ul><ul><li>Sedatives </li></ul></ul><ul><ul><li>Dopamine agonists </li></ul></ul>
  55. 55. Pharmacologic Management of Daily RLS <ul><ul><li>Dopamine agonists </li></ul></ul><ul><ul><li>Anticonvulsants </li></ul></ul><ul><ul><li>Opioids </li></ul></ul><ul><ul><li>Benzodiazepines </li></ul></ul>
  56. 56. Refractory RLS <ul><li>Change to a different dopamine agonist </li></ul><ul><li>Switch to an opioid or anticonvulsant </li></ul><ul><li>Add a second medication </li></ul><ul><li>Consider a drug holiday </li></ul><ul><li>High-potency opioids for severe, reistant cases: methadone </li></ul>
  57. 57. Prognosis <ul><li>Primary RLS is </li></ul><ul><ul><li>Life long disorder </li></ul></ul><ul><ul><li>Symptom severity waxes and wanes over time </li></ul></ul><ul><ul><li>Increase risk that biological relatives will have RLS </li></ul></ul>
  58. 58. Summary <ul><li>Adult </li></ul><ul><li>Type of RLS </li></ul><ul><li>Primary or Secondary </li></ul><ul><li>Diagnostic Criteria </li></ul><ul><li>Evaluate and treatment symptomatic RLS </li></ul><ul><li>Nonpharmacologic treatments may be helpful </li></ul><ul><li>Treatment of choice </li></ul><ul><li>Dopaminergics </li></ul><ul><li>Child </li></ul><ul><li>Type of RLS </li></ul><ul><li>Primary </li></ul><ul><li>Diagnostic Criteria </li></ul><ul><li>Evaluate and treatment symptomatic RLS </li></ul><ul><li>Nonpharmacologic treatments may be helpful </li></ul><ul><li>Treatment of choice </li></ul><ul><li>Nonpharmacolgic treatments </li></ul>
  59. 59. <ul><li>“ Sometimes I wish I could cut my legs off”. </li></ul><ul><li>Patient with RLS </li></ul>
  60. 60. Acknowledgements <ul><li>All thanks and glory to God </li></ul><ul><li>I also want to thank my family, </li></ul><ul><li>Jonathan Stubbs and Amanda Washington </li></ul><ul><li>NMA </li></ul><ul><li>Calvin Wheeler, M.D. </li></ul><ul><li>Mrs. Francis Dillard </li></ul><ul><li>Art Walters, M.D. </li></ul><ul><li>David Rye, M.D. </li></ul><ul><li>Daniel Picchietti, M.D. </li></ul><ul><li>Members of the Central Virginia RLS Support Group </li></ul>

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