Lifestyle Changes, Medications, and More -

Several prescription medications are used to treat RLS. They’re typically taken at night, one or two hours before symptoms begin, says Preeti Devnani, MD, a staff physician at the Cleveland Clinic Sleep Disorders Center and a fellow of the AASM. Some are taken only when symptoms tend to crop up, such as before a long flight. Others are taken daily. Each medication comes with its own set of potential side effects.

“Ask your healthcare provider what medication may be best for you given the severity and timing of your symptoms,” Dr. Devnani says.

Gabapentinoids as First-Line Treatment

The updated AASM guidelines recommend gabapentinoids as the first-line treatment for adults with RLS. Gabapentinoids are part of a drug class called anticonvulsants or antiseizure-antiepileptic drugs. They include:

gabapentin (Neurontin, Gralise)
gabapentin enacarbil (Horizant)
pregabalin (Lyrica, Lyrica CR)

These drugs work by affecting the chemical messengers in your brain and nerves, reducing abnormal levels of excitation in the brain. Gabapentinoids come as tablets, capsules, and oral solutions.

Although it’s not entirely clear how they work to treat RLS, gabapentinoids have shown significant efficacy in reducing RLS symptoms without significant side effects.

“Most patients tolerate these medications well,” says Alon Avidan, MD, MPH, professor of neurology at UCLA and director of the UCLA Sleep Disorders Center in Los Angeles.

“However, as with most medications that work on the brain, the side effects may be a limitation and may include dizziness, sleepiness, fatigue, swelling of the legs, and weight gain. The side effects may be reduced when patients begin therapy at low doses and increase to higher doses slowly over time.”

Patients should also be evaluated for misuse risks, adds Devnani, as some patients may become addicted to the drugs. “Side effects can also include respiratory depression in patients with untreated obstructive sleep apnea,” she says.

Dopaminergic Drugs May Do More Harm Than Good in the Long Run

A key change in the guidelines is that the AASM now advises against the long-term use of dopaminergic drugs such as:

ropinirole (Requip)
pramipexole (Mirapex)
rotigotine (Neupro)

Dopaminergic drugs work by either helping the brain release more dopamine (an important neurotransmitter or brain chemical) or replacing it altogether. While these drugs can help treat RLS in the short term, new evidence shows that in the long term, they can worsen the symptoms through a phenomenon called augmentation.

This doesn’t mean that dopaminergic drugs are completely off the table. The guidelines note that the drugs may still be used to treat people for whom immediate short-term relief is more important than the long-term effects.

Your healthcare provider should carefully advise you of the short- and long-term risks and side effects of these drugs.

Switching From Dopaminergic Drugs to Gabapentinoids

If you’ve been taking dopaminergic drugs for a long time, your doctor may now recommend switching you to gabapentinoids in light of the new guidelines. “Educating patients about their lower risk of augmentation [with gabapentinoids] and long-term efficacy of medication outcomes is vital,” says Devnani.

However, abruptly stopping dopamine medications can produce withdrawal symptoms. “To minimize this side effect, it’s often recommended that we introduce the new medication while the patients are still using their dopamine-type drugs. Patients are instructed to slowly wean off the dopamine medications over time (four to six weeks),” says Dr. Avidan.

“Another suggestion is to introduce the gabapentinoids medication to an effective dose before tapering off the dopaminergic medication. Dopamine agonist tapering, done slowly over the course of a month, is generally well-tolerated and successful,” says Avidan. “My experience shows that in some patients, complete discontinuation of the dopaminergic medication may not always be possible.”

Devnani adds that opioids may be used carefully during the weaning process to manage any breakthrough symptoms. It’s also very important to schedule regular follow-ups to monitor symptoms or side effects during this time.

Source link