Restless Leg Syndrome “ The most common disorder you have never heard of.”

What are Restless legs? Neurological movement disorder Irresistible urge to move legs when at rest Difficulty sleeping Involuntary periodic leg movements Uncomfortable sensation in limbs subjective & difficult to describe Symptoms eased by movement

Why should we know about it? Excess 5 million in UK are sufferers (MEMO 2000) Estimated prevalence 2-15% Sufferers will present to primary care Important physical cause of sleep disturbance Clinical diagnosis which can be made in primary care

Why should we know about it? Unrecognised & under-diagnosed Incorrectly labeled as stress / anxiety Managed poorly

Wide spectrum Affects any age group More common in middle age + women Mild Minimal distress Severe Episodes occur >2 per week Can be disabling

Why is it important? Large impact on quality of life: (REST Study) Poor sleep Inability to get comfortable / relax Poor concentration / fatigue Pain Depression Problems in day to day functioning / employment Implications for partner

Common descriptive terms used by patients

How do we diagnosis RLS? International Restless Legs Syndrome Study Group

Supporting Features Positive FHx (50-92%) Involuntary limb movements (80%) Sleep disturbance

What investigations should we do? Exclude secondary cause. Vascular dx / Neuropathy / nocturnal cramp / anxiety Examination Neuro / vascular Bloods FBC, ferritin, B12, Folate, U&E, Glucose, TFT

Aetiology Primary No underlying cause found. Positive FHx >50% Earlier onset / slower progression Secondary Fe deficiency Pregnancy End stage renal disease Peripheral neuropathy / DM / RA / Fibromyalgia Later onset / more severe

Pathophysiology Genetic Susceptibility loci identified on 3 chromosomes Positive FHx >50% Neurochemical Dopaminergic dysfunction - universal response to dopaminergic agents Ferritin level - inverse relation between severity and serum ferritin

What are the treatment options? Non Pharmacological Preventative measures Symptomatic control Pharmacological PRN treatment - mild / intermittent Maintenance treatment - moderate / severe Majority of treatments used ‘off license’

Non pharmacological treatment Preventative Avoid caffeine / alcohol / nicotine Avoid medication which may aggravate SSRI / antihistamine / antiemetic / CaChannel blockers Keep active into evening Good sleep hygiene Symptom control Mental alerting activities Walking / stretching Massage Hot / cold bath Relaxation / biofeedback

Pharmacological options DrugAdvantageDisadvantage IronHelpful if serum ferritin low Slow response Dopamine agonist Pramipexole / ropinirole High efficacy (70-100%) Less augmentation Daytime sleepiness Long term effect not known Dopaminergic agent Carbidopa / levodopa Can be used PRN basis Shown to be effective Up to 80% develop augmentation

Pharmacological options DrugAdvantageDisadvantage Anticonvulsants Gabapentin / Carbamazepine Useful in neuropathy / associated pain Side effect profile BenzosPRN use + help sleep Cognitive impairment, dependence OpioidsPRN use / daytime use Cognitive impairment, dependence

Rx Flow chart - RLS:UK

Mirapexin (pramipexole) First drug treatment / ONLY treatment licensed in EU for RLS For use in moderate / severe disease Quick onset of symptom relief (<1/52) Start low dose 125mcg od Titrate up (max 750mcg od)

What should we be doing? Have raised awareness about diagnosis Exclude / treat secondary causes Symptoms generally mild + reassurance & non-pharmacological measures suffice In moderate / severe cases consider onward referral

Useful Info Resources Review DTB Nov 2003 Bandolier 118