RLS Guidelines Change and Clinical Pearls
Restless Legs Syndrome (RLS) can be a very difficult diagnosis to manage for some patients. Insomnia, pain and significant discomfort can result on account of this disease. Here are a few of my favorite clinical pearls and with a critical update in the RLS guidelines.
Assess for iron deficiency first. It is easy to add new medications to try to solve a problem. The harder thing to do is to investigate why a patient is having problems in the first place. Iron deficiency can cause symptoms of restless legs and checking ferritin to assess iron stores is critical. The most recent guidelines set the ferritin mark at 75ng/mL. If patients are below this level, oral iron is recommended in most situations.
With the latest RLS guidelines, Alpha-2-delta calcium channel ligands (gabapentin or pregabalin) are the preferred drug of choice. This is new to me as dopamine agonists have historically been used first-line by many clinicians that I have worked with. There may be situations where we would want to avoid these agents. If patients have obesity, significant depression, or a history of drug use disorder(s), you’ll likely pick dopamine agonists over these medications. Here’s the link to the latest guidelines.
If dopamine agonists are used, remember that there is a rare reported side effect that has made the news. These drugs have been associated with unusual compulsive type behaviors. Gambling, shopping, eating, and hypersexuality have all been reported.
Remember the dose-dependent absorption issue with gabapentin. As you get to higher dosages, there is the potential that you won’t have as good of an effect as you might anticipate. I discuss the pharmacokinetics of gabapentin and this issue in greater detail in this previous article.
What other clinical pearls are critical in RLS?