neurologic disorders
Periodic Limb Movement Disorder (PLMD) and Restless Legs Syndrome (RLS)
Treatment of PLMD and RLS
For RLS:Pramipexole,ropinirole, arotigotinepatch, orgabapentinenacarbil, plus iron supplements if ferritin is < 50 ng/mL For PLMD: Usually the same treatments as for RLS For restless legs syndrome and periodic limb movement disorder, numerous drugs (eg, dopaminergic drugs, benzodiazepines, antiseizure drugs, vitamins and minerals) are used. Dopaminergic drugs, although often effective, may have adverse effects such as augmentation (RLS symptoms that worsen before the next drug dose is given and that affect other body parts such as the arms), rebound (symptoms that worsen after the drug is stopped or after the effects of the drug dissipate), nausea, orthostatic hypotension, compulsive activity, and insomnia. Threedopamineagonists,pramipexole,ropinirole, androtigotine(used as a patch), are effective and have few serious adverse effects other than augmentation: Pramipexole0.125 mg is given orally 2 hours before onset of moderate to severe symptoms and is increased, as needed, by 0.125 mg orally every 2 nights until symptoms are relieved (maximum dose 0.5 mg). Ropinirole0.25 mg is given orally 1 to 3 hours before onset of symptoms and is increased, as needed, by 0.25 mg nightly (maximum dose 4 mg). Therotigotinepatch (1 mg/24 hours) is initially applied any time during the day; dosage is increased as needed by 1 mg/24 hours at weekly intervals, up to 3 mg/24 hours. Levodopa/carbidopamay be used, but other drugs, which are less likely to cause augmentation and rebound symptoms, are usually preferred. Gabapentinmay help relieve RLS symptoms and is used when RLS is accompanied by pain. Dosing begins with 300 mg at bedtime and can be increased by 300 mg weekly (maximum dose 900 mg orally 3 times a day). However,gabapentinis not approved for the treatment of RLS. Gabapentinenacarbil, a prodrug ofgabapentin, may help relieve RLS symptoms; it is approved for the treatment of RLS. The recommended dose is 600 mg once a day taken with food at about 5pm. Its most common adverse effects include somnolence and dizziness. It is less likely to cause augmentation than the dopaminergic drugs. Pregabalin, a nondopaminergic alpha-2-delta ligand, may help relieve RLS symptoms; augmentation is less likely to occur than withpramipexole.Pregabalinmay also be useful for RLS accompanied by pain. For RLS, a dose of 300 mg once a day has been used. Dizziness and somnolence are the most common adverse effects. However, use of this drug to treat RLS has not been extensively studied. Benzodiazepinesmay improve sleep continuity but do not reduce limb movements; they should be used cautiously to avoid tolerance, exacerbation of sleep apnea (if present), and daytime sleepiness. Opioid Analgesics None Ferritin levels should be obtained, and if levels are low (<50 mcg/L), supplementation with ferrous sulfate 325 mg plus 100 to 200 mg of vitamin C at bedtime is warranted. Patients should implement good Sleep Hygiene . 