The Management of Restless Legs Syndrome: An Updated Algorithm.

Restless legs syndrome (RLS) is a common disorder. The population prevalence is 1.5% to 2.7% in a subgroup of patients having more severe RLS with symptoms occurring 2 or more times a week and causing at least moderate distress. It is important for primary care physicians to be familiar with the disorder and its management. Much has changed in the management of RLS since our previous revised algorithm was published in 2013. This updated algorithm was written by members of the Scientific and Medical Advisory Board of the RLS Foundation based on scientific evidence and expert opinion. A literature search was performed using PubMed identifying all articles on RLS from 2012 to 2020. The management of RLS is considered under the following headings: General Considerations; Intermittent RLS; Chronic Persistent RLS; Refractory RLS; Special Circumstances; and Alternative, Investigative, and Potential Future Therapies. Nonpharmacologic approaches, including mental alerting activities, avoidance of substances or medications that may exacerbate RLS, and oral and intravenous iron supplementation, are outlined. The choice of an alpha2-delta ligand as first-line therapy for chronic persistent RLS with dopamine agonists as a second-line option is explained. We discuss the available drugs, the factors determining which to use, and their adverse effects. We define refractory RLS and describe management approaches, including combination therapy and the use of high-potency opioids. Treatment of RLS in pregnancy and childhood is discussed.

Guidelines for the first-line treatment of restless legs syndrome/Willis-Ekbom disease, prevention and treatment of dopaminergic augmentation: a combined task force of the IRLSSG, EURLSSG, and the RLS-foundation.

A Task Force was established by the International Restless Legs Syndrome Study Group (IRLSSG) in conjunction with the European Restless Legs Syndrome Study Group (EURLSSG) and the RLS Foundation (RLS-F) to develop evidence-based and consensus-based recommendations for the prevention and treatment of long-term pharmacologic treatment of dopaminergic-induced augmentation in restless legs syndrome/Willis-Ekbom disease (RLS/WED). The Task Force made the following prevention and treatment recommendations: As a means to prevent augmentation, medications such as α2δ ligands may be considered for initial RLS/WED treatment; these drugs are effective and have little risk of augmentation. Alternatively, if dopaminergic drugs are elected as initial treatment, then the daily dose should be as low as possible and not exceed that recommended for RLS/WED treatment. However, the physician should be aware that even low dose dopaminergics can cause augmentation. Patients with low iron stores should be given appropriate iron supplementation. Daily treatment by either medication should start only when symptoms have a significant impact on quality of life in terms of frequency and severity; intermittent treatment might be considered in intermediate cases. Treatment of existing augmentation should be initiated, where possible, with the elimination/correction of extrinsic exacerbating factors (iron levels, antidepressants, antihistamines, etc.). In cases of mild augmentation, dopamine agonist therapy can be continued by dividing or advancing the dose, or increasing the dose if there are breakthrough night-time symptoms. Alternatively, the patient can be switched to an α2δ ligand or rotigotine. For severe augmentation the patient can be switched either to an α2δ ligand or rotigotine, noting that rotigotine may also produce augmentation at higher doses with long-term use. In more severe cases of augmentation an opioid may be considered, bypassing α2δ ligands and rotigotine.

Willis-Ekbom Disease Foundation revised consensus statement on the management of restless legs syndrome.

Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) is a common disorder, occurring at least twice a week and causing at least moderate distress in 1.5% to 2.7% of the population. It is important for primary care physicians to be familiar with this disorder and its management. Much has changed in its management since our previous algorithm was published in 2004, including the availability of several new drugs. This revised algorithm was written by members of the Medical Advisory Board of the Willis-Ekbom Disease Syndrome Foundation based on scientific evidence and expert opinion. It considers the management of RLS/WED under intermittent RLS/WED, chronic persistent RLS/WED, and refractory RLS/WED. Nonpharmacological approaches, including mental alerting activities, avoiding substances or medications that may exacerbate RLS, and the role of iron supplementation, are outlined. Chronic persistent RLS/WED should be treated with either a nonergot dopamine agonist or a calcium channel α-2-δ ligand. We discuss the available drugs, the factors determining which to use, and their adverse effects. We define refractory RLS/WED and describe management approaches, including combination therapy and the use of high-potency opioids.

Sleep-related movement disorders.

PURPOSE OF REVIEW: This article reviews the sleep-related movement disorders, including restless legs syndrome (RLS; Willis-Ekbom disease), periodic limb movement disorder, rhythmic movement disorders, sleep-related bruxism, and sleep-related leg cramps. RECENT FINDINGS: The prevalence of clinically significant RLS is 1.5% to 3.0%. The pathophysiology of RLS may involve abnormal iron transport across the blood-brain barrier and down-regulation of putaminal D2 receptors. The availability of the rotigotine patch provides an additional form of dopaminergic therapy for RLS. Calcium channel alpha-2-delta ligands (gabapentin, gabapentin enacarbil, and pregabalin) provide alternative therapies for RLS especially in patients with augmentation, impulse control disorders, or hypersomnia induced by dopamine agonists. Long-term use of opioid medication is safe and effective for refractory cases of RLS. SUMMARY: RLS is a common disorder causing considerable morbidity. Accurate diagnosis and appropriate investigations are essential. Many effective therapies are available, but the side effects of each class of medication should be considered in determining optimal treatment. Periodic limb movements of sleep, bruxism, and rhythmic movement disorders are sleep-related phenomena often accompanying other sleep disorders and only sometimes requiring primary therapy. Sleep-related leg cramps are generally idiopathic. Management is challenging with few effective therapies.

The treatment of parasomnias with hypnosis: a 5-year follow-up study.

STUDY OBJECTIVES: This study involves a replication and extension of a previous one reported by Hurwitz et al (1991) on the treatment of certain parasomnias with hypnosis. METHODS: Thirty-six patients (17 females), mean age 32.7 years (range 6-71). Four were children aged 6 to 16. All had chronic, "functionally autonomous" (self-sustaining) parasomnias. All underwent 1 or 2 hypnotherapy sessions and were then followed by questionnaire for 5 years. RESULTS: Of the 36 patients, 45.4% were symptom-free or at least much improved at the 1-month follow-up, 42.2% at the 18-month follow-up, and 40.5% at the 5-year follow-up. CONCLUSIONS: One or 2 sessions of hypnotherapy might be an efficient first-line therapy for patients with certain types of parasomnias.