Restless legs syndrome

Encyclopedia of Medicine, Apr 06, 2001 by Ann M. Haren

In some people whose symptoms cannot be linked to a treatable associated condition, drug therapy may be necessary to provide relief and restore a normal sleep pattern. Prescription drugs that are normally used for RLS include:

• Benzodiazepines and low-potency opioids. These drugs are prescribed for use only on an "as needed" basis, for patients with mild RLS. Benzodiazepines appear to reduce nighttime awakenings due to PLMS. The benzodiazepine most commonly used to treat RLS is clonazepam (Klonopin, Rivotril). The main disadvantage of this drug type is that it causes daytime drowsiness. It also causes unsteadiness that may lead to accidents, especially for an elderly patient. Opioids are narcotic pain relievers. Those commonly used for mild RLS are low potency opioids, such as codeine (Tylenol #3) and propoxyphene (Darvocet). Studies have shown that these can be successfully used in the treatment of RLS on a long-term basis without risk of addiction. However, narcotics can cause constipation and difficulty urinating.
• Levodopa (L-dopa) and carbidopa (Sinemet). Levodopa is the drug most commonly used to treat moderate or severe RLS. It acts by supplying a chemical called dopamine to the brain. It is often taken in conjunction with carbidopa to prevent or decrease side effects. Although it is effective against RLS, levodopa may also causes a worsening of symptoms during the afternoon or early evening in 50-80% of patients. This phenomenon is known as "restless legs augmentation," and if it occurs, the physician will probably discontinue Levodopa for a brief period while an alternate drug is used. Levodopa can often be reintroduced after a short break.
• Pergolide (Permax). Pergolide acts on the same part of the brain as Levodopa. It is less likely than Levodopa to cause daytime worsening of symptoms (occurs in about 25% of patients). However, it is not recommended as the first choice in drug therapy since it causes a high rate of minor side effects. Pergolide is often used only if Levodopa has been discontinued.
• High potency opioids. If the symptoms of RLS are difficult to treat with the above medication, higher dose opioids will be used. These include methadone (Dolophine), oxycodone, and clonidine (Catapres, Combipres, Dixarit). A significant disadvantage of these drugs is risk of addiction.
• Anticonvulsants. Some cases of RLS may be improved by anticonvulsant drugs, such as carbamazepine (Tegretol).
• Combination therapy. Some patients respond well to combinations of drugs such as a benzodiazepine and Levodopa.

Many drugs have been investigated for treatment of RLS, but it seems as though the perfect therapy has not yet been found. However, careful monitoring of side effects and good communication between patient and doctor can result in a flexible program of therapy that minimizes side effects and maximizes effectiveness.

It is likely that the best alternative therapy will combine both conventional and alternative approaches. Levodopa may be combined with a therapy that relieves pain, relaxes muscles, or focuses in general on the nervous system and the brain. Any such combined therapy that allows a reduction in dosage of levodopa is advantageous, since this will reduce the likelihood of unacceptable levels of drug side effects. Of course, the physician who prescribes the medication should monitor any combined therapy. Alternative methods may include: