Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease in adults and children: an IRLSSG task force report

Primary healthcare nurses' experiences of symptoms and treatment needs of patients with RLS-associated symptoms at telephone nursing - an abductive analysis based on the Four Habits communication model

BACKGROUND

Restless legs syndrome (RLS) is a common, neurological disease. Primary healthcare (PHC) nurses are often the patient's first contact, but studies regarding their experience assessing RLS-associated symptoms and treatment needs in telephone nursing (TN) are lacking.

PURPOSE

To describe how PHC nurses experience symptoms and treatment needs of patients with RLS-associated symptoms during TN.

METHODS

A descriptive abductive design, including semi-structured interviews with 18 PHC nurses from six Swedish regions. Data was deductively analyzed using the Four Habits communication model. Facilitators and barriers were inductively identified.

RESULTS

Invest in the beginning included the use of professional competence, interpretation of influencing factors at the start of the conversation and initial understanding of the patient's RLS symptoms. Elicit the patient's perspective involved originate from the patient's perception of the symptoms and comprehending the symptoms' impact on the patient's life situation. Relate to the patient's situation and the importance of trust in the patient meeting described demonstrating empathy. Invest in the end involved triaging patients with RLS-associated symptoms, providing self-care advice to patients with RLS-associated symptoms and achieving consensus at the end of the conversation.

CONCLUSION

Using the Four Habits communication model could enrich communication regarding RLS-associated symptoms and treatment needs during TN.

Therapy of Childhood Restless Legs Syndrome and Periodic Limb Movement Disorder

This article describes the complex landscape of pediatric Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD); prevalent sleep disorders posing challenges to affected children and healthcare providers. It emphasizes a multifaceted treatment approach integrating pharmacologic and non-pharmacologic interventions tailored to individual needs. Iron supplementation emerges as a cornerstone, supported by studies linking low iron levels to sleep disturbances in various pediatric populations. Non-pharmacologic interventions, including lifestyle modifications and dietary adjustments, play a crucial role. The article underscores the importance of personalized management and ongoing research to enhance outcomes and quality of life for children with RLS and PLMD.

Iron Metabolism and the Role of Iron Therapy in Pediatric Restless Leg Syndrome

Iron metabolism in the body is strictly regulated and organ specific. Intestinal iron absorption is mediated through complex mechanisms and is mainly regulated by a peptide called hepcidin that controls iron fluxes into plasma. Iron is transported by circulating transferrin and is stored in the protein called ferritin. Iron homeostasis in the brain is regionally regulated through complex interactions involving many genes and biochemical pathways under circadian influences. This article reviews iron metabolism and how brain iron deficiency plays a role in the pathogenesis of restless leg syndrome (RLS). The role of iron therapy in management of RLS and PLMD in pediatric population will be discussed.

Mimics of Childhood Restless Legs Syndrome

Restless legs syndrome (RLS), also known as Willis-Ekbom Disease (WED), has several mimicking conditions that closely resemble many, if not all, of its characteristics. Some of these mimics are particularly prevalent in pediatric populations. A thorough differential diagnosis of RLS/WED must be grounded in a comprehensive patient history, physical examination, and laboratory findings. Accurate diagnosis is crucial to ensuring appropriate treatment, optimizing functional outcomes, and preventing both unnecessary parental concern and potential side effects from incorrect therapies.

Iron Deficiency in Adults: A Review

Importance

Absolute iron deficiency, defined as low iron stores with or without anemia, affects approximately 2 billion people worldwide and 14% of adults in the US. Iron-deficiency anemia, defined as low hemoglobin due to low iron stores, affects approximately 1.2 billion people worldwide, including 10 million in the US.

Observations

Absolute iron deficiency progresses from low iron stores to iron-deficiency anemia. Individuals with nonanemic iron deficiency or iron-deficiency anemia may be asymptomatic or experience fatigue, irritability, depression, difficulty concentrating, restless legs syndrome (32%-40%), pica (40%-50%), dyspnea, lightheadedness, exercise intolerance, and worsening heart failure (HF). Symptom prevalences vary depending on age, comorbidities (eg, chronic kidney disease [CKD], HF), and severity and rate of development of iron deficiency. The most common causes of iron deficiency are bleeding (menstrual, gastrointestinal), impaired iron absorption (atrophic gastritis, celiac disease, bariatric surgical procedures), inadequate dietary iron intake, and pregnancy. In high-income countries, approximately 38% of nonpregnant, reproductive-age women have iron deficiency without anemia and about 13% have iron-deficiency anemia. During the third trimester of pregnancy, iron deficiency affects up to 84% of pregnant women, based on data from high-income countries. Additional risk factors include use of nonsteroidal anti-inflammatory drugs, inflammatory bowel disease (IBD [13%-90%]), and other chronic inflammatory conditions, such as CKD (24%-85%), HF (37%-61%), and cancer (18%-82%). Testing for iron deficiency is indicated for patients with anemia and/or symptoms of iron deficiency (fatigue, pica, or restless legs syndrome) and should be considered for those with risk factors such as heavy menstrual bleeding, pregnancy, or IBD. Iron deficiency is diagnosed by low serum ferritin (typically <30 ng/mL) in individuals without inflammatory conditions or by transferrin saturation (iron/total iron binding capacity × 100) less than 20%. Causes of iron deficiency should be identified and treated. Oral iron (ferrous sulfate 325 mg/d or on alternate days) is typically first-line therapy. Intravenous iron is indicated for patients with oral iron intolerance, poor absorption (celiac disease, post-bariatric surgical procedure), chronic inflammatory conditions (CKD, HF, IBD, cancer), ongoing blood loss, and during the second and third trimesters of pregnancy.

Conclusions and Relevance

Iron deficiency and iron-deficiency anemia are common conditions that may cause symptoms such as fatigue, exercise intolerance, and difficulty concentrating. Ferritin and/or transferrin saturation are required for diagnosis and screening. Oral iron is first-line therapy for most patients. Intravenous iron is used for individuals who do not tolerate or have impaired absorption of oral iron, those with ongoing blood loss, certain chronic inflammatory conditions (IBD, CKD, HF, cancer), and during the second and third trimesters of pregnancy.

Acute-Onset Disabling Restless Legs Syndrome and Periodic Limb Movements in a Context of Mesenteric Ischemia: Successful Management With Intravenous Iron Supplementation

An 87-year-old woman with a history of multiple cardiovascular conditions, diabetes mellitus, and chronic renal failure developed insomnia and restless leg syndrome (RLS) with periodic limb movements during hospitalization for superior mesenteric artery ischaemia, which was successfully treated by mechanical embolectomy. She was found to be anaemic, with a haemoglobin at 10.5 g/dL (reference range: 11.8 15 g/dL) and serum ferritin at 13μg/L (reference range: 30 400μg/L). Given the severity of her symptoms and iron deficiency, we opted against oral iron supplementation, as its absorption is slower and less efficient. Instead, we administered intravenous iron sucrose as a first-line treatment, resulting in a corrected ferritin level of 90μg/L. Her RLS symptoms regressed within two days after intravenous iron supplementation. This case highlights the importance of considering RLS in patients presenting with insomnia, as effective treatments are available to improve patient outcomes.

Intravenous iron in chronic kidney disease without anaemia but iron deficiency: A scoping review

Iron deficiency (ID) is a prevalent complication of chronic kidney disease (CKD), often managed reactively when associated with anaemia. This scoping review evaluates the evidence supporting intravenous (IV) iron therapy in non-anaemic individuals with CKD and ID, focusing on safety, efficacy, and emerging therapeutic implications. Current diagnostic markers, including serum ferritin, transferrin saturation, and reticulocyte haemoglobin content, are reviewed alongside their limitations in the context of inflammation and variability. The pathophysiology of ID in CKD is explored, highlighting the roles of hepcidin, hypoxia-inducible factor pathways, and uraemic toxins. Comparative studies reveal that IV iron offers a more rapid correction of iron stores, improved compliance, and fewer gastrointestinal side effects compared to oral iron. Evidence from trials such as "iron and heart" and "iron and muscle" suggests potential benefits of IV iron on functional capacity and fatigue, though findings were statistically non-significant. Insights from heart failure trials support the safety and efficacy of IV iron in improving quality of life and reducing hospitalizations, with newer formulations like ferric derisomaltose demonstrating favourable safety profiles. This review underscores the need for standardized screening protocols for ID in CKD, even in the absence of anaemia, to facilitate earlier intervention. Future research should prioritise robust outcome measures, larger sample sizes, and person-specific treatment strategies to optimise dosing and administration frequency. Tailored approaches to IV iron therapy have the potential to significantly improve functional outcomes, quality of life, and long-term health in people with CKD.

Sleep and Cancer

Background/Objectives: Sleep issues are common in the general population, and these problems occur even more frequently for people with cancer. Sleep problems may pre-exist a patient's cancer diagnosis, and there is a growing interest in understanding the impact of sleep on cancer development and progression. Sleep disorders may impact cancer through altered metabolism, impacts on immune response, and alterations in hormones and gene expression. Sleep disorders may also arise after, or be aggravated by, an individual's cancer and cancer treatment. Treating a person with cancer's sleep disorder may help improve their healing, mental health, cognition, and overall resilience. Methods: Studies examining a variety of aspects of the relationship between sleep and cancer were found by searching the National Library of Medicine and characterized by their specific information provided on the relationship between sleep and cancer. Results: This review article summarizes our current understanding of the complex inter-relationship between sleep and cancer, the underlying mechanisms that create these connections, and the methods and impact of treating sleep issues in cancer patients. The article also outlines an approach to sleep complaints for clinicians caring for patients with cancer. Conclusions: Significant research is still needed to understand the full relationship between sleep disorders and cancer. The impact of sleep issues on cancer and of cancer on sleep appears to be specific to the tissue and the molecular type of cancer. The treatment of sleep disorders is multimodal, and offers a promising avenue to improve the health and quality of life of cancer patients.

Evidence of Involvement of the Calcitonin Gene-Related Peptide in Restless Legs Syndrome

BACKGROUND

Restless legs syndrome (RLS) is a common sensory-motor disorder characterized by an urge to move the legs, often with unpleasant sensations, particularly during rest. Current treatments include iron supplementation, dopamine agonists, and opioids, but new therapeutic approaches are needed. The dysfunction of the A11 nucleus, which modulates dopaminergic transmission to the spinal cord, is thought to play a role in RLS pathophysiology. Calcitonin gene-related peptide (CGRP), which is involved in pain modulation, may interact with A11 pathways, suggesting a role in RLS.

OBJECTIVES

This study aimed to assess the involvement of CGRP in RLS by determining if CGRP-related proteins are overexpressed in RLS patients.

METHODS

A cross-sectional study was conducted with 17 drug-free RLS patients (mean age 55.8 years) and 17 age- and gender-matched controls. Serum samples were analyzed using liquid chromatography-parallel reaction monitoring-tandem mass spectrometry (LC-PRM-MS/MS) to identify and quantify CGRP-related proteins. Principal component analysis (PCA) was used to differentiate between groups.

RESULTS

PCA showed clear differentiation between RLS and control groups. Among 13 identified CGRP-related proteins, 10 were dysregulated in RLS patients: 8 were upregulated, and 2 were downregulated, among them notable proteins such as S100A12, ADM, SRSF6, and ADM2.

CONCLUSIONS

This study indicates the significant involvement of CGRP and related proteins in RLS. This suggests these proteins may play roles in various aspects of the disorder. Further research is required to validate these findings and explore their clinical implications, including development of new treatment options that specifically address CGRP pathways. © 2025 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Serum ferritin measurements differ according to the assay used: implications for iron therapy in restless legs syndrome

STUDY OBJECTIVES

Serum ferritin levels are used to determine the need for iron supplementation in patients with restless legs syndrome. The purpose of this study was to determine whether immunoassay measurement of serum ferritin yields varying levels according to different manufacturers' assays, with resultant variation in cutoff values.

METHODS

We compared serum ferritin levels using 116 clinical samples assessed by the Beckman and Roche methods.

RESULTS

Although there was a high correlation between results obtained from the 2 methods (R2 = 0.99), the absolute values differed. The equivalent ferritin measures determined by the Beckman and Roche methods were 50 μg/dl, 83 μg/dl; 75 μg/dl, 121 μg/dl; 100 μg/dl, 158 μg/dl; and 300 μg/dl, 457 μg/dl.

CONCLUSIONS

It is uncertain which assays were used to measure serum ferritin in the seminal studies on which current guidelines for iron therapy for restless legs syndrome are based. In view of this uncertainty, as well as the limited data on which current recommendations are based, clinicians should be flexible in using recommended serum ferritin cutoff values, also using percentage of transferrin saturation. Assuming that Beckman or equivalent assays were used, centers using the Roche method need to adjust the cutoffs for administration of oral iron and intravenous iron recommended by current practice guidelines to avoid withholding treatment for restless legs syndrome patients who might benefit from iron supplementation.

CITATION

Silber MH, Block DR, St. Louis EK. Serum ferritin measurements differ according to the assay used: implications for iron therapy in restless legs syndrome. J Clin Sleep Med. 2025;21(1):65-67.

Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine clinical practice guideline

INTRODUCTION

This guideline establishes clinical practice recommendations for treatment of restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) in adults and pediatric patients.

METHODS

The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using the grading of recommendations assessment, development, and evaluation methodology. The task force provided a summary of the relevant literature and the certainty of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations that support the recommendations. The AASM Board of Directors approved the final recommendations.

GOOD PRACTICE STATEMENT

The following good practice statement is based on expert consensus, and its implementation is necessary for the appropriate and effective management of patients with RLS.

1. In all patients with clinically significant RLS, clinicians should regularly test serum iron studies including ferritin and transferrin saturation (calculated from iron and total iron binding capacity). Testing should ideally be administered in the morning avoiding all iron-containing supplements and foods at least 24 hours prior to blood draw. Analysis of iron studies greatly influences the decision to use oral or intravenous (IV) iron treatment. Consensus guidelines, which have not been empirically tested, suggest that supplementation of iron in adults with RLS should be instituted with oral or IV iron if serum ferritin ≤ 75 ng/mL or transferrin saturation < 20%, and only with IV iron if serum ferritin is between 75 and 100 ng/mL. In children, supplementation of iron should be instituted for serum ferritin < 50 ng/mL with oral or IV formulations. These iron supplementation guidelines are different than for the general population.

2. The first step in the management of RLS should be addressing exacerbating factors, such as alcohol, caffeine, antihistaminergic, serotonergic, antidopaminergic medications, and untreated obstructive sleep apnea.

3. RLS is common in pregnancy; prescribers should consider the pregnancy-specific safety profile of each treatment being considered.

RECOMMENDATIONS

The following recommendations are intended as a guide for clinicians in choosing a specific treatment for RLS and PLMD in adults and children. Each recommendation statement is assigned a strength ("strong" or "conditional"). A "strong" recommendation (ie, "We recommend…") is one that clinicians should follow under most circumstances. The recommendations listed below are ranked in the order of strength of recommendations and grouped by class of treatments within each PICO (Patient, Intervention, Comparator, Outcome) question. Some recommendations include remarks that provide additional context to guide clinicians with implementation of this recommendation.

ADULTS WITH RLS

1. In adults with RLS, the AASM recommends the use of gabapentin enacarbil over no gabapentin enacarbil (strong recommendation, moderate certainty of evidence).

2. In adults with RLS, the AASM recommends the use of gabapentin over no gabapentin (strong recommendation, moderate certainty of evidence).

3. In adults with RLS, the AASM recommends the use of pregabalin over no pregabalin (strong recommendation, moderate certainty of evidence).

4. In adults with RLS, the AASM recommends the use of IV ferric carboxymaltose over no IV ferric carboxymaltose in patients with appropriate iron status (see good practice statement for iron parameters) (strong recommendation, moderate certainty of evidence).

5. In adults with RLS, the AASM suggests the use of IV low molecular weight iron dextran over no IV low molecular weight iron dextran in patients with appropriate iron status (see good practice statement for iron parameters) (conditional recommendation, very low certainty of evidence).

6. In adults with RLS, the AASM suggests the use of IV ferumoxytol over no IV ferumoxytol in patients with appropriate iron status (see good practice statement for iron parameters) (conditional recommendation, very low certainty of evidence).

7. In adults with RLS, the AASM suggests the use of ferrous sulfate over no ferrous sulfate in patients with appropriate iron status (see good practice statement for iron parameters) (conditional recommendation, moderate certainty of evidence).

8. In adults with RLS, the AASM suggests the use of dipyridamole over no dipyridamole (conditional recommendation, low certainty of evidence).

9. In adults with RLS, the AASM suggests the use of extended-release oxycodone and other opioids over no opioids (conditional recommendation, moderate certainty of evidence).

10. In adults with RLS, the AASM suggests the use of bilateral high-frequency peroneal nerve stimulation over no peroneal nerve stimulation (conditional recommendation, moderate certainty of evidence).

11. In adults with RLS, the AASM suggests against the standard use of levodopa (conditional recommendation, very low certainty of evidence).

Remarks: levodopa may be used to treat RLS in patients who place a higher value on the reduction of restless legs symptoms with short-term use and a lower value on adverse effects with long-term use (particularly augmentation).

12. In adults with RLS, the AASM suggests against the standard use of pramipexole (conditional recommendation, moderate certainty of evidence).

Remarks: pramipexole may be used to treat RLS in patients who place a higher value on the reduction of restless legs symptoms with short-term use and a lower value on adverse effects with long-term use (particularly augmentation).

13. In adults with RLS, the AASM suggests against the standard use of transdermal rotigotine (conditional recommendation, low certainty of evidence).

Remarks: transdermal rotigotine may be used to treat RLS in patients who place a higher value on the reduction of restless legs symptoms with short-term use and a lower value on adverse effects with long-term use (particularly augmentation).

14. In adults with RLS, the AASM suggests against the standard use of ropinirole (conditional recommendation, moderate certainty of evidence).

Remarks: ropinirole may be used to treat RLS in patients who place a higher value on the reduction of restless legs symptoms with short-term use and a lower value on adverse effects with long-term use (particularly augmentation).

15. In adults with RLS, the AASM suggests against the use of bupropion for the treatment of RLS (conditional recommendation, moderate certainty of evidence).

16. In adults with RLS, the AASM suggests against the use of carbamazepine (conditional recommendation, low certainty of evidence).

17. In adults with RLS, the AASM suggests against the use of clonazepam (conditional recommendation, very low certainty of evidence).

18. In adults with RLS, the AASM suggests against the use of valerian (conditional recommendation, very low certainty of evidence).

19. In adults with RLS, the AASM suggests against the use of valproic acid (conditional recommendation, low certainty of evidence).

20. In adults with RLS, the AASM recommends against the use of cabergoline (strong recommendation, moderate certainty of evidence).

SPECIAL ADULT POPULATIONS WITH RLS

21. In adults with RLS and end-stage renal disease (ESRD), the AASM suggests the use of gabapentin over no gabapentin (conditional recommendation, very low certainty of evidence).

22. In adults with RLS and ESRD, the AASM suggests the use of IV iron sucrose over no IV iron sucrose in patients with ferritin < 200 ng/mL and transferrin saturation < 20% (conditional recommendation, moderate certainty of evidence).

23. In adults with RLS and ESRD, the AASM suggests the use of vitamin C over no vitamin C (conditional recommendation, low certainty of evidence).

24. In adults with RLS and ESRD, the AASM suggests against the standard use of levodopa (conditional recommendation, low certainty of evidence).

Remarks: levodopa may be used to treat RLS in patients who place a higher value on the reduction of restless legs symptoms with short-term use and a lower value on adverse effects with long-term use (particularly augmentation).

25. In adults with RLS and ESRD, the AASM suggests against the standard use of rotigotine (conditional recommendation, very low certainty of evidence).

Remarks: rotigotine may be used to treat RLS in patients who place a higher value on the reduction of restless legs symptoms with short-term use and a lower value on adverse effects with long-term use (particularly augmentation).

ADULTS WITH PLMD

26. In adults with PLMD, the AASM suggests against the use of triazolam (conditional recommendation, very low certainty of evidence).

27. In adults with PLMD, the AASM suggests against the use of valproic acid (conditional recommendation, very low certainty of evidence).

CHILDREN WITH RLS

28. In children with RLS, the AASM suggests the use of ferrous sulfate over no ferrous sulfate in patients with appropriate iron status (see good practice statement for iron parameters) (conditional recommendation, very low certainty of evidence).

CITATION

Winkelman JW, Berkowski JA, DelRosso LM, et al. Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2025;21(1):137-152.

Assessing Sleep Disorders in an Inpatient Child and Adolescent Psychiatric Unit

Sleep and mental health have a strong relationship. There is a lack of training in Sleep Medicine for Psychiatrists. Sleep problems often accompany mental health issues, especially in children and adolescents on inpatient psychiatry units. Recognizing common sleep disorders is important in these settings. It is also important to involve pediatric sleep specialists when needed. This article addresses common sleep disorders observed in inpatient child and adolescent psychiatry units and outlines optimal management strategies.

Identification of Causal Genes and Potential Drug Targets for Restless Legs Syndrome: A Comprehensive Mendelian Randomization Study

Background: Restless legs syndrome (RLS) is a common sensorimotor sleep disorder that affects sleep quality of life. Much effort has been made to make progress in RLS pharmacotherapy; however, patients with RLS still report poor long-term symptom control. Methods: Comprehensive Mendelian randomization (MR) was performed to search for potential causal genes and drug targets using the cis-pQTL and RLS GWAS data. Robustness was validated using the summary-based Mendelian randomization (SMR) method and co-localization analysis. Further evidence of pleiotropy of the target genes and their potential side effects was provided by phenome-wide MR analysis (MR-PheWAS). Finally, molecular docking simulations were conducted on drug candidates corresponding to these targets, which revealed promising binding affinities and interaction patterns and underscored the druggable potential of the target gene. All of the analyses above were conducted in the context of Homo sapiens. Results:MAN1A2 showed a statistically significant result in the MR analysis, which was validated through SMR and co-localization analysis. The MR-PheWAS showed a low probability of pleiotropy and prospective side effects. Molecular docking was used to visualize the binding structure and fine affinity for MAN1A2 and the drugs predicted by DSigDB. Conclusions: Our study provides comprehensive evidence supporting MAN1A2 as a promising causal gene and therapeutic target for RLS, offering insights into the underlying molecular mechanisms and paving the way for future drug development efforts.

Circadian Pattern in Restless Legs Syndrome: Implications for Treatment Posology

The symptoms of restless legs syndrome (RLS) follow a circadian pattern, as inducated in the current RLS diagnostic criteria. Indeed, subjects with mild-to-moderate RLS suffer or not from RLS symptoms depending on the time of day, resembling an above-threshold state periodically followed by a below-threshold state. Although the circadian clock is crucial in the clinical features of RLS, research assessing the ultimate drivers of circadian rhythmicity is still very limited. In the present review, we show current evidence on circadian variations of neurotransmitters involved in the pathophysiology of RLS (systemic iron metabolism, brain iron homeostasis, adenosine, dopamine, glutamate, and endogenous opioids). Secondly, an overview of available therapies for RLS is presented, including information on current recommendations for symptomatic treatments in RLS. We discuss the importance of further research into the circadian oscillations that occur in RLS, so that they can be managed, and a protective below-threshold state can be established on an individualized basis. In addition, we also discuss the current dosing of the medications prescribed in RLS symptomatic treatments, and how circadian factors should be considered to better adjust dosing on an individualized basis and increase the therapeutic benefit.

Sleep-related movement disorders in children: recent updates

BACKGROUND

Sleep-related movement disorders (SRMDs), such as restless legs syndrome (RLS) and periodic limb movement disorder (PLMD), are common in pediatric sleep practice. There is increasing literature on RLS, PLMD, and a newly described sleep disorder called "restless sleep disorder (RSD)". We aimed to review and provide recent updates on SRMDs.

DATA SOURCES

A comprehensive search for relevant English-language peer-reviewed publications focused on three common SRMDs, namely, RLS, PLMD and RSD, in a variety of indices in PubMed and SCOPUS. Both relevant databases and systematic reviews are included.

RESULTS

SRMDs, especially RLS and PLMD, are common in children and adolescents. However, they are underrecognized. Genetics, abnormal dopaminergic functions, and iron deficiency are the main pathophysiologies of RLS and PLMD. RLS and RSD may share common pathophysiologic mechanisms, as evidenced by low iron stores in both conditions. The diagnoses of RLS, PLMD, and RSD require specific clinical criteria and polysomnographic features. Several comorbid conditions have been associated with RLS, PLMD, and RSD. Iron therapy has been shown to be effective for treating RLS, PLMD, and RSD. There is increasing evidence on the effectiveness of specific medications in children with RLS and PLMD, but the data are still limited.

CONCLUSIONS

This review summarizes the pathophysiology, clinical manifestations, diagnostic criteria, and management of RLS, PLMD, and RSD in children based on relevant and recent literature. It is important for pediatricians to recognize the clinical presentation of RLS, PLMD, and RSD to facilitate early diagnosis. Further studies are needed to examine the pathogenesis, long-term consequences, and pharmacologic therapy of RSD in children.

Pharmacological and non-pharmacological management of sleep disturbances in Parkinson's disease: if when and how

INTRODUCTION

Sleep dysfunction occurs in various forms and is a bothersome and intrusive non-motor symptom of Parkinson's disease (PD). Frequently undiagnosed, their poor management can have a great impact on the quality of life of PD patients and their caregivers.

AREAS COVERED

This article covers the safety and efficacy of pharmacological strategies for the management of the most frequent sleep disturbances in Parkinson's disease. Non-pharmacological aspects are also discussed, but these are not the main focus. Literature searches using electronic databases (Medline, Cochrane Library) and systematic checking of references from review articles/other reports were performed.

EXPERT OPINION

Melatonin and clonazepam are the most commonly used therapies for the management of REM sleep behavior disorder (RBD). The most used pharmacological wake-promoting agents in the treatment of excessive daytime sleepiness (EDS) are modafinil and caffeine. Poor nocturnal sleep quality is usually linked to EDS, thus proper sleep hygiene is recommended. As nocturnal motor symptoms are commonly associated with sleep fragmentation and early morning off, optimization of dopaminergic treatment during nighttime is highly recommended for the proper management of insomnia. Further interventions include eszopiclone and melatonin for the management of insomnia. Therapeutic options for restless legs syndrome (RLS) include calcium channel alpha-2-delta ligands and low-dose dopamine agonists (DA). Further confirmatory evidence is needed before the general recommendation of these treatments.

Diagnosis and Treatment of Iron Deficiency and Iron Deficiency Anemia in Children and Adolescents: Recommendations of the Polish Pediatric Society, the Polish Society of Pediatric Oncology and Hematology, the Polish Society of Neonatology, and the Polish Society of Family Medicine

Background/Objectives. Iron deficiency is one of the most common nutritional deficiencies worldwide and is the leading cause of anemia in the pediatric population (microcytic, hypochromic anemia due to iron deficiency). Moreover, untreated iron deficiency can lead to various systemic consequences and can disrupt the child's development. Methods/Results. Therefore, a team of experts from the Polish Pediatric Society, the Polish Society of Pediatric Oncology and Hematology, the Polish Neonatology Society, and the Polish Society of Family Medicine, based on a review of the current literature, their own clinical experience, and critical discussion, has developed updated guidelines for the diagnosis, prevention, and treatment of iron deficiency in children from birth to 18 years of age. These recommendations apply to the general population and do not take into account the specifics of individual conditions and diseases.

Sleep Disorders

AbstractThere are more than 90 recognized sleep disorders, many of which impair sleep and daytime function and adversely impact heath, well-being, and chronic disease risk. Unfortunately, many sleep disorders are undiagnosed or not managed effectively. This review describes how to identify, evaluate, and treat common sleep disorders.

Rethinking clinical trials in restless legs syndrome: A roadmap

The number of large clinical trials of restless legs syndrome (RLS) have decreased in recent years, this coincides with reduced interest in developing and testing novel pharmaceuticals. Therefore, the International Restless Legs Syndrome Study Group (IRLSSG) formed a task force of global experts to examine the causes of these trends and make recommendations to facilitate new clinical trials. In our article, we delve into potential complications linked to the diagnostic definition of RLS, identify subpopulations necessitating more attention, and highlight issues pertaining to endpoints and study frameworks. In particular, we recommend developing alternative scoring methods for more accurate RLS diagnosis, thereby improving clinical trial specificity. Furthermore, enhancing the precision of endpoints will increase study effect sizes and mitigate study costs. Suggestions to achieve this include developing online, real-time sleep diaries with high-frequency sampling of nightly sleep latency and the use of PLMs as surrogate markers. Furthermore, to reduce the placebo response, strategies should be adopted that include placebo run-in periods. As RLS is frequently a chronic condition, priority should be given to long-term studies, using a randomized, placebo-controlled, withdrawal design. Lastly, new populations should be investigated to develop targeted treatments such as mild RLS, pregnancy, hemodialysis, or iron-deficient anemia.

Current and emerging pharmaceutical strategies for the treatment and management of restless legs syndrome

INTRODUCTION

Restless legs syndrome (RLS) is a sensory-motor sleep disorder that affects up to 13% of adults in the Western world and 2-4% of children. It impairs night sleep with an impact on daily performances and life quality. Thus, moderate-to-severe RLS requires pharmacological treatment.

AREAS COVERED

In the present review, which is based on PubMed searches with no time limits, the authors discuss the recommended pharmacotherapy for RLS in addition to other emerging treatment options. The authors provide coverage to the current recommendations for both adults and pediatric patients with RLS.

EXPERT OPINION

Current evidence suggests removing all causes of secondary RLS, including iron deficiency, chronic renal failure, drugs, and treating other sleep disorders that may worsen symptoms. Also, intermittent RLS should be addressed with behavioral measures and on-demand therapy. For chronic persistent RLS, α2δ calcium channel ligands are a first-line pharmacological approach, whereas dopamine agonists are associated with increased risk and should be spared. When RLS is refractory to first-line treatment, polytherapy, or opioid monotherapy should be considered. Nonetheless, some patients may not reach sustained symptom relief. Further research is needed to better understand the pathophysiology of RLS and to develop newer more effective drugs.

Transcutaneous electrical nerve stimulation in the management of restless legs syndrome symptoms: A single-blind, parallel-group clinical study

The aim of this study was to investigate the additional effect of transcutaneous electrical nerve stimulation (TENS) on the control of the symptoms of restless legs syndrome (RLS). A total of 46 randomly selected patients diagnosed with RLS were divided into two groups in a single-blind study to either receive pramipexole (0.25 mg daily) plus 10 sessions of TENS or only pramipexole (0.25 mg daily) for 4 weeks. The severity of the symptoms was determined according to the International Restless Legs Syndrome Rating Scale (IRLSRS) and the Pittsburgh sleep quality index (PSQI) at the beginning of the treatment, post-treatment, and at an 8 week follow-up. A significant time interaction was observed between the groups for all measurement outcomes, revealing differences in favour of the experimental group's IRLSRS and PSQI scores. A notable improvement was also observed in the IRLSRS and PSQI scores in both groups at the end of treatment and during the 8 week follow-up period. In comparison with pramipexole monotherapy, the results of this study showed that the use of TENS therapy combined with a low dose of pramipexole (0.25 mg daily) is therapeutically beneficial in the treatment of RLS over an 8 week follow-up period.

Iron Deficiency and Restless Sleep/Wake Behaviors in Neurodevelopmental Disorders and Mental Health Conditions

Iron deficiency (ID) and restlessness are associated with sleep/wake-disorders (e.g., restless legs syndrome (RLS)) and neurodevelopmental disorders (attention deficit/hyperactivity and autism spectrum disorders (ADHD; ASD)). However, a standardized approach to assessing ID and restlessness is missing. We reviewed iron status and family sleep/ID history data collected at a sleep/wake behavior clinic under a quality improvement/quality assurance project. Restlessness was explored through patient and parental narratives and a 'suggested clinical immobilization test'. Of 199 patients, 94% had ID, with 43% having a family history of ID. ADHD (46%) and ASD (45%) were common conditions, along with chronic insomnia (61%), sleep-disordered breathing (50%), and parasomnias (22%). In unadjusted analysis, a family history of ID increased the odds (95% CI) of familial RLS (OR: 5.98, p = 0.0002, [2.35-15.2]), insomnia/DIMS (OR: 3.44, p = 0.0084, [1.37-8.64]), and RLS (OR: 7.00, p = 0.01, [1.49-32.93]) in patients with ADHD, and of insomnia/DIMS (OR: 4.77, p = 0.0014, [1.82-12.5]), RLS/PLMS (OR: 5.83, p = 0.009, [1.54-22.1]), RLS (OR: 4.05, p = 0.01, [1.33-12.3]), and familial RLS (OR: 2.82, p = 0.02, [1.17-6.81]) in patients with ASD. ID and restlessness were characteristics of ADHD and ASD, and a family history of ID increased the risk of sleep/wake-disorders. These findings highlight the need to integrate comprehensive blood work and family history to capture ID in children and adolescents with restless behaviors.

Iron Deficiency and Sleep/Wake Behaviors: A Scoping Review of Clinical Practice Guidelines-How to Overcome the Current Conundrum?

Current evidence suggests that iron deficiency (ID) plays a key role in the pathogenesis of conditions presenting with restlessness such as attention deficit hyperactivity disorder (ADHD) and restless legs syndrome (RLS). In clinical practice, ID and iron supplementation are not routinely considered in the diagnostic work-up and/or as a treatment option in such conditions. Therefore, we conducted a scoping literature review of ID guidelines. Of the 58 guidelines included, only 9 included RLS, and 3 included ADHD. Ferritin was the most frequently cited biomarker, though cutoff values varied between guidelines and depending on additional factors such as age, sex, and comorbidities. Recommendations surrounding measurable iron biomarkers and cutoff values varied between guidelines; moreover, despite capturing the role of inflammation as a concept, most guidelines often did not include recommendations for how to assess this. This lack of harmonization on the interpretation of iron and inflammation biomarkers raises questions about the applicability of current guidelines in clinical practice. Further, the majority of ID guidelines in this review did not include the ID-associated disorders, ADHD and RLS. As ID can be associated with altered movement patterns, a novel consensus is needed for investigating and interpreting iron status in the context of different clinical phenotypes.

Diagnosis and management of anemia in pediatric inflammatory bowel diseases: Clinical practice guidelines on behalf of the SIGENP IBD Working group

Anemia is one of the most frequent extra-intestinal manifestations of inflammatory bowel disease. Insidious onset, variability of symptoms and lack of standardized screening practices may increase the risk of underestimating its burden in children with IBD. Despite its relevance and peculiarity in everyday clinical practice, this topic is only dealt with in a few documents specifically for the pediatric field. The aim of the current guidelines is therefore to provide pediatric gastroenterologists with a practical update to support the clinical and therapeutic management of children with IBD and anemia. A panel of 19 pediatric gastroenterologists and 1 pediatric hematologist with experience in the field of pediatric IBD was agreed by IBD Working group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) to produce the present article outlining practical clinical approaches to the pediatric patient with IBD and anemia. The levels of evidence and recommendations have been defined for each part of the statement according to the GRADE system.

Effects of Dietary Supplementation in Patients with Restless Legs Syndrome: A Systematic Review

Restless legs syndrome (RLS) is a common neurological disorder. It disrupts sleep and well-being and is often associated with other conditions. This review examines the potential of dietary supplements to manage RLS symptoms and reduce reliance on medications. A total of 10 randomized clinical trials involving 482 participants were analyzed, focusing on the impact of various supplements on symptom severity, sleep quality, and daytime sleepiness. Findings suggest some supplements may have positive results. Magnesium oxide and vitamin B6 significantly improved sleep quality and RLS symptoms, with magnesium showing greater effectiveness. Vitamin D supplementation did not show significant benefits. Oral iron has promising results, indicating potential efficacy but issues related to compliance and absorption. Both vitamins C and E positively affect RLS symptoms, likely due to their antioxidant properties. Valerian improved RLS and sleep but did not show a statistically significant improvement. Despite these encouraging results, a high risk of bias was noted in half of the studies, emphasizing the need for more rigorous research. Overall, this review suggests that dietary supplements may be a promising approach to managing RLS. However, further investigation is required to confirm the efficacy and safety.

Clinical efficacy and safety of intravenous ferric carboxymaltose for treatment of restless legs syndrome: a multicenter, randomized, placebo-controlled clinical trial

STUDY OBJECTIVES

Iron therapy is associated with improvements in restless legs syndrome (RLS). This multicenter, randomized, double-blind study evaluated the effect of intravenous ferric carboxymaltose (FCM) on RLS.

METHODS

A total of 209 adult patients with a baseline International RLS (IRLS) score ≥ 15 were randomized (1:1) to FCM (750 mg/15 mL) or placebo on study days 0 and 5. Ongoing RLS medication was tapered starting on Day 5, with the goal of discontinuing treatment or achieving the lowest effective dose. Co-primary efficacy endpoints were changed from baseline in IRLS total score and the proportion of patients rated as much/very much improved on the Clinical Global Impression (CGI)-investigator (CGI-I) scale at day 42 in the "As-Treated" population.

RESULTS

The "As-Treated" population comprised 107 FCM and 101 placebo recipients; 88 (82.2%) and 68 (67.3%), respectively, completed the day 42 assessment. The IRLS score reduction was significantly greater with FCM versus placebo: least-squares mean (95% confidence interval [CI]) -8.0 (-9.5, -6.4) versus -4.8 (-6.4, -3.1); p = .0036. No significant difference was observed in the proportion of FCM (35.5%) and placebo (28.7%) recipients with a CGI-I response (odds ratio 1.37 [95% CI: 0.76, 2.47]; p = .2987). Fewer patients treated with FCM (32.7%) than placebo (59.4%) received RLS interventions between day 5 and study end (p = .0002). FCM was well tolerated.

CONCLUSIONS

The IRLS score improved with intravenous FCM versus placebo, although the combination of both co-primary endpoints was not met. Potential methodological problems in the study design are discussed.

Mild behavioral impairment domains are longitudinally associated with pTAU and metabolic biomarkers in dementia-free older adults

BACKGROUND

The mechanisms linking mild behavioral impairment (MBI) and Alzheimer's disease (AD) have been insufficiently explored, with conflicting results regarding tau protein and few data on other metabolic markers. We aimed to evaluate the longitudinal association of the MBI domains and a spectrum of plasma biomarkers.

METHODS

Our study is a secondary analysis of data from NOLAN. The longitudinal association of the MBI domains with plasma biomarkers, including pTau181, was tested using adjusted linear mixed-effects models.

RESULTS

The sample comprised 359 participants (60% female, mean age: 78.3, standard deviation: 0.3 years). After 1 year, the MBI domain of abnormal perception was associated with steeper increases in plasma pTau181. Abnormal perception, decreased motivation, and impulse dyscontrol were associated with homocysteine or insulin dysregulation.

DISCUSSION

Apart from the association with plasma pTau181, our results suggest that MBI might also represent metabolic dysregulation, probably contributing to dementia transition among older adults with subjective cognitive decline or mild cognitive impairment.

HIGHLIGHTS

Mild behavioral impairment (MBI) psychosis was associated with steeper increases in plasma p. pTau could be a pharmacological target to treat agitation and psychosis symptoms. MBI domains were linked to metabolic dysregulation involving insulin and homocysteine.

A survey-based approach on restless legs syndrome: practices and perspectives among Italian neurologists

INTRODUCTION

Restless Legs Syndrome (RLS) is a widely prevalent and complex neurological disorder. Despite notable advancements in managing RLS, the disorder continues to face challenges related to its recognition and management.

OBJECTIVE

This study seeks to gain comprehensive insights into the knowledge and clinical practices among Italian neurologists regarding RLS diagnosis, management, and treatment, comparing approaches among general neurologists, movement disorder specialists, and sleep experts.

METHODS

Members of the Italian Society of Neurology, the Italian Society of Parkinson and Movement Disorders, and the Italian Association of Sleep Medicine were invited to participate in a 19-question online survey.

RESULTS

Among the 343 surveyed neurologists, 60% categorized RLS as a "sleep-related movement disorder." Forty% indicated managing 5-15 RLS patients annually, with sleep specialists handling the highest patient volume. Of note, only 34% adhered strictly to all five essential diagnostic criteria. The majority (69%) favored low-dosage dopamine agonists as their first-line treatment, with movement disorder specialists predominantly endorsing this approach, while sleep experts preferred iron supplementation. Regular screening for iron levels was widespread (91%), with supplementation typically guided by serum iron alterations. In cases of ineffective initial treatments, escalating dopamine agonist dosage was the preferred strategy (40%).

CONCLUSIONS

These findings underscore a lack of a clear conceptualization of RLS, with a widespread misconception of the disorder as solely a movement disorder significantly influencing treatment approaches. Disparities in RLS understanding across neurology subspecialties underscore the necessity for improved diagnostic accuracy, targeted educational initiatives, and management guidelines to ensure consistent and effective RLS management.

Non-motor symptoms in patients with amyotrophic lateral sclerosis: current state and future directions

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease characterized by the progressive degeneration of both upper and lower motor neurons. A defining histopathological feature in approximately 97% of all ALS cases is the accumulation of phosphorylated trans-activation response (TAR) DNA-binding protein 43 protein (pTDP-43) aggregates in the cytoplasm of neurons and glial cells within the central nervous system. Traditionally, it was believed that the accumulation of TDP-43 aggregates and subsequent neurodegeneration primarily occurs in motor neurons. However, contemporary evidence suggests that as the disease progresses, other systems and brain regions are also affected. Despite this, there has been a limited number of clinical studies assessing the non-motor symptoms in ALS patients. These studies often employ various outcome measures, resulting in a wide range of reported frequencies of non-motor symptoms in ALS patients. The importance of assessing the non-motor symptoms reflects in a fact that they have a significant impact on patients' quality of life, yet they frequently go underdiagnosed and unreported during clinical evaluations. This review aims to provide an up-to-date overview of the current knowledge concerning non-motor symptoms in ALS. Furthermore, we address their diagnosis and treatment in everyday clinical practice.

Iron deficiency in children with a focus on inflammatory conditions

Iron deficiency (ID) tends to be overlooked compared with anemia. However, its prevalence is estimated to be twice as high as that of ID anemia, and ID without anemia can be accompanied by clinical and functional impairments. The symptoms of ID are nonspecific, such as fatigue and lethargy, but can lead to neurodevelopmental disorders in children, restless legs syndrome, and recurrent infections due to immune system dysregulation. In particular, the risk of ID is high in the context of chronic inflammatory diseases (CIDs) due to the reaction of various cytokines and the resulting increase in hepcidin levels; ID further exacerbates these diseases and increases mortality. Therefore, the diagnosis of ID should not be overlooked through ID screening especially in high-risk groups. Ferritin and transferrin saturation levels are the primary laboratory parameters used to diagnose ID. However, as ferritin levels respond to inflammation, the diagnostic criteria differ among guidelines. Therefore, new tools and criteria for accurately diagnosing ID should be developed. Treatment can be initiated only with an accurate diagnosis. Oral iron is typically the first-line treatment for ID; however, the efficacy and safety of intravenous iron have recently been recognized. Symptoms improve quickly after treatment, and the prognosis of accompanying diseases can also be improved. This review highlights the need to improve global awareness of ID diagnosis and treatment, even in the absence of anemia, to improve the quality of life of affected children, especially those with CIDs.

A randomized double-blind pilot study to evaluate the efficacy, safety, and tolerability of intravenous iron versus oral iron for the treatment of restless legs syndrome in patients with iron deficiency anemia

Restless legs syndrome (RLS) is a neurological disorder that can have a profound effect on sleep and quality of life. Idiopathic RLS is associated with brain iron insufficiency despite normal peripheral iron stores. There is, however, a five- to six-fold increase in prevalence of RLS in patients with iron deficiency anemia (IDA). Several open-label trials have demonstrated symptomatic improvement in RLS following treatment of IDA using oral or intravenous iron supplementation. To date, there have been no randomized double-blind controlled trials of intravenous iron compared with oral iron for the treatment of RLS patients with IDA. In the current study, oral ferrous sulfate and ferumoxytol were compared for efficacy and speed of response for treatment of RLS occurring in patients with IDA. The planned recruitment for this study was 70 patients with RLS and IDA, to be randomly assigned 1:1 to oral or intravenous iron, using double-blind, double-dummy procedures. At Week 6, the primary outcomes of Clinical Global Impression-Improvement score and change from baseline in the International Restless Legs Syndrome Study Group rating scale score were assessed. Due to challenges, performing the clinical trial during the COVID-19 pandemic, final-week data were found missing for 30 patients. As a result, in order to maintain the prespecified statistical analysis, an additional 30 patients were recruited. Both IV and oral iron were associated with a marked improvement in RLS symptoms, with no statistically significant difference between treatment groups. No serious adverse events were observed in either treatment group.

Too little or too much nocturnal movements in Parkinson's disease: A practical guide to managing the unseen

Nocturnal and sleep-related motor disorders in people with Parkinson's disease (PD) have a wide spectrum of manifestations and present a complex clinical picture. Problems can arise due to impaired movement ability (hypokinesias), e.g. nocturnal hypokinesia or early-morning akinesia, or to excessive movement (hyperkinesias), e.g. end-of-the-day dyskinesia, parasomnias, periodic limb movement during sleep and restless legs syndrome. These disorders can have a significant negative impact on the sleep, daytime functional ability, and overall quality of life of individuals with PD and their carers. The debilitating motor issues are often accompanied by a combination of non-motor symptoms, including pain and cramping, which add to the overall burden. Importantly, nocturnal motor disorders encompass a broader timeline than just the period of sleep, often starting in the evening, as well as occurring throughout the night and on awakening, and are not just limited to problems of insomnia or sleep fragmentation. Diagnosis can be challenging as, in many cases, the 'gold standard' assessment method is video polysomnography, which may not be available in all settings. Various validated questionnaires are available to support evaluation, and alternative approaches, using wearable sensors and digital technology, are now being developed to facilitate early diagnosis and monitoring. This review sets out the parameters of what can be considered normal nocturnal movement and describes the clinical manifestations, usual clinical or objective assessment methods, and evidence for optimal management strategies for the common nocturnal motor disorders that neurologists will encounter in people with PD in their clinical practice.

Self-administered non-invasive vagus nerve stimulation therapy for severe pharmacoresistant restless legs syndrome: outcomes at 6 months

Severe pharmacoresistant restless legs syndrome (RLS) is difficult to manage and a source of suffering to patients. We studied the effectiveness at 6 months of an innovative treatment: transauricular vagus nerve stimulation (taVNS) in the left cymba concha in a case series of 15 patients, 53% male, mean (SD) age 62.7 (12.3) years with severe pharmacoresistant RLS (mean [SD] International Restless Legs Rating Scale [IRLS] score of 31.9 [2.9]) at baseline. Following an 8-week non-randomised hospital-based study with eight 1-h sessions of taVNS, patients were trained to administer taVNS at home and were followed up for 6 months. The primary outcome measure was the IRLS score, secondary outcome measures were quality of life, mood disorders using the Hospital Anxiety and Depression scale (HAD) subscales for depression (HADD) and anxiety (HADA). At the 6-month follow-up 13/15 patients continued to use weekly taVNS. Symptom severity decreased (mean [SD] IRLS score 22.2 [9.32] at 6 months, p = 0.0005). Four of the 15 patients had an IRLS score of <20 at 6 months and two an IRLS score of 5. Quality of life significantly improved compared to baseline (mean [SD] score at baseline 49.3 [18.1] versus 65.66 [22.58] at 6 months, p = 0.0005) as did anxiety and depression symptoms (mean [SD] HADA score at baseline 8.9 [5.4] versus 7.53 [4.42] at 6 months, p = 0.029; and HADD score at baseline 5.2 [4.5] versus 4.73 [4.44] at 6 months, p = 0.03). Treatment was well tolerated, and no adverse events were reported. Our case series shows a potential role for self-administered taVNS in patients with severe pharmacoresistant RLS. Randomised controlled trials are needed to confirm the utility of taVNS.

Sleep disturbances in children and adolescents after kidney transplantation

BACKGROUND

Disturbances of sleep are prevalent among children with chronic kidney disease. However, the aetiology of sleep disorders in children particularly after kidney transplantation is not clear. We sought to ascertain the prevalence and type of sleep disturbances in paediatric kidney transplant recipients and to identify predictors of sleep disturbances in this population.

METHODS

Caregivers of kidney transplant recipients completed online questionnaires about their child's sleep. The questionnaires utilised were the Sleep Disturbance Scale for Children (SDSC), the Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD), questions about sleep hygiene, and questions about restless leg syndrome. Demographic and clinical details were collected from medical records.

RESULTS

Thirty-five children were included in the study, with a median (IQR) age of 14.1 years (9.5-16.1) and median years (IQR) since transplant of 3.7 (0.7-8.7) years, and 72.0% were identified to have at least one category of sleep disturbance according to scores on the SDSC. The most common sleep disturbances reported were disorders of initiating and maintaining sleep (DIMS) (40.0%) and disorders of excessive somnolence (DOES) (31.4%). Statistically significant predictors of sleep disturbances include low estimated glomerular filtration rate and increased age. Among children who screened positive for DIMS and DOES, the majority indicated use of electronic devices in 1 h before bed.

CONCLUSIONS

A high prevalence of sleep disturbances has been identified in children after kidney transplants, and some risk factors may be modifiable. Further studies are required to understand whether there are other readily modifiable predictors of sleep disturbances.

Anticonvulsant Agents for Treatment of Restless Legs Syndrome: A Case Report With Lamotrigine and a Review of the Literature

INTRODUCTION

Restless Legs Syndrome (RLS) is a neurological disorder primarily treated with pregabalin and gabapentin, followed by dopamine agonists later in the process due to the risk of augmenting RLS symptoms. In addition, clinical reports have disclosed varying degrees of success employing other agents in patients unresponsive to traditional agents. Here, we present a patient who had success in the reduction of RLS symptoms with lamotrigine, a broad-spectrum anticonvulsant. Previously, lamotrigine had been used in 2 trials with successful treatment of RLS.

CASE REPORT

We present a 58-year-old right-handed lady with long-standing history of smoking, hypertension, dyslipidaemia, prediabetes, gastro-esophageal reflux disease, asthma, strabismus, uterine cancer, severe and debilitating course of RLS accompanied by unexplained deterioration. The patient initially demonstrated abnormal sensation in all her limbs, which worsened with radiotherapy treatment, and was eventually diagnosed with RLS based on the diagnostic criteria. Subsequent examinations were unremarkable and revealed no further explanation for the deterioration of the RLS symptoms. While the complexity of the patient's medical history had exposed her to a variety of medications, she reported that only lamotrigine, in addition to her original regimen of methadone and pramipexole, offered significant symptomatic relief. It must be noted that no adverse side effects, including impulse-control disorder, were reported by the patient.

CONCLUSIONS

We present a case of a woman whose deteriorating symptoms of RLS were successfully alleviated by the administration of lamotrigine. This is only the third case in the literature to have successfully utilized lamotrigine as a treatment option for RLS.

Restless leg syndrome as a complication of primary hyperparathyroidism: insights from a retrospective study

INTRODUCTION

Restless leg syndrome (RLS) is an invalidating neurological disorder with a complex, largely unknown pathophysiology. While RLS is observed in Parkinson's disease and in renal failure, idiopathic cases are common. Limited reports associate RLS with parathyroid hormone (PTH). This study analyzes a cohort of patients with primary hyperparathyroidism (PHPT) and chronic post-surgical hypoparathyroidism (hypo PTH), to investigate RLS prevalence, and associated risk factors.

METHODS

Ninety-five patients (54 PHPT, 41 hypo PTH) were consecutively enrolled at the bone metabolism outpatient clinic. The revised IRLSSG diagnostic criteria were used to diagnose RLS, with assessments conducted through face-to-face interviews and neurological examination. When RLS was confirmed, the RLS severity scale was applied. Retrospective records included calcium-phosphate metabolism-related parameters, surgery details, renal lithiasis, fragility fractures, and densitometric features (T-score).

RESULTS

RLS was diagnosed in 22.2% PHPT patients, compared to 4.9% of patients with hypo PTH (p = 0.02). Of RLS diagnosed patients, 91.7% had a history of parathyroidectomy, compared to 47.6% of patients without RLS (p = 0.01). Most of the operated patients reported that surgery determined an improvement of symptoms; however, mean score severity of RLS at our evaluation was 15/40, defined as moderate. PTH and calcium levels were not statistically associated to the presence of RLS.

CONCLUSION

Our study suggests that PHPT may be one of the etiologies of RLS. Parathyroidectomy alleviates symptoms in the vast majority of the cases but does not remove them.

Current updates in Restless Legs Syndrome: A pragmatic review

Restless legs syndrome (RLS), also called Willis–Ekbom disease (WED), affects approximately 3% of the global population, with higher incidence in Caucasians and women. This review explores the latest advancements in the diagnosis, pathophysiology, and management of RLS, and it highlights the recent changes in diagnostic criteria that improve specificity. The diagnostic spectrum now includes atypical presentations involving the upper limbs and other body parts. The new diagnostic specifiers categorize RLS more effectively into chronic-persistent or intermittent types, and a clinical significance specifier has been introduced to better address the disorder’s effects on daily life. RLS management has shifted toward a balanced approach with non-pharmacological strategies and lifestyle changes, supported by updated pharmacological treatment protocols including iron therapy designed to mitigate risks such as augmentation. Notably, gabapentinoids have emerged as a superior treatment option over dopamine agonists owing to their lower risk of augmentation and superior safety profile. Innovative treatments, such as the FDA-approved tonic motor activation device and new pharmacological agents, serve as alternatives for treating medication-refractory RLS, thereby expanding the therapeutic landscape. Additionally, this review addresses the specific considerations for managing RLS in special groups, including pregnant women, individuals with chronic kidney disease, and patients with comorbid conditions such as Parkinson’s disease and multiple sclerosis. We emphasizes the dynamic nature of RLS research and highlight the critical need for ongoing studies to further elucidate the complex mechanisms underlying RLS, as well as to refine the treatment modalities to enhance patient outcomes.

Unveiling the pathophysiology of restless legs syndrome through transcriptome analysis

The aim of this study was to analyze signaling pathways associated with differentially expressed messenger RNAs in people with restless legs syndrome (RLS). Seventeen RLS patients and 18 controls were enrolled. Coding RNA expression profiling of 12,857 gene transcripts by next-generation sequencing was performed. Enrichment analysis by pathfindR tool was carried-out, with p-adjusted ≤0.001 and fold-change ≥2.5. Nine main different network groups were significantly dysregulated in RLS: infections, inflammation, immunology, neurodegeneration, cancer, neurotransmission and biological, blood and metabolic mechanisms. Genetic predisposition plays a key role in RLS and evidence indicates its inflammatory nature; the high involvement of mainly neurotropic viruses and the TORCH complex might trigger inflammatory/immune reactions in genetically predisposed subjects and activate a series of biological pathways-especially IL-17, receptor potential channels, nuclear factor kappa-light-chain-enhancer of activated B cells, NOD-like receptor, mitogen-activated protein kinase, p53, mitophagy, and ferroptosis-involved in neurotransmitter mechanisms, synaptic plasticity, axon guidance, neurodegeneration, carcinogenesis, and metabolism.

Restless legs syndrome, neuroleptic-induced akathisia, and opioid-withdrawal restlessness: shared neuronal mechanisms?

Restlessness is a core symptom underlying restless legs syndrome (RLS), neuroleptic-induced akathisia, and opioid withdrawal. These three conditions also share other clinical components suggesting some overlap in their pathophysiology. Recent prospective studies demonstrate the frequent incidence of RLS-like symptoms during opioid withdrawal and supervised prescription opioid tapering. Based on the therapeutic role of µ-opioid receptor (MOR) agonists in the three clinical conditions and recent preclinical experimental data in rodents, we provide a coherent and unifying neurobiological basis for the restlessness observed in these three clinical syndromes and propose a heuristic hypothesis of a key role of the specific striatal neurons that express MORs in akathisia/restlessness.

A comprehensive update on the ADMET considerations for α2δ calcium channel ligand medications for treating restless legs syndrome

INTRODUCTION

Restless legs syndrome/Willis-Ekbom disease (RLS/WED) is a sleep-related sensory-motor disorder associated with poor sleep quality and impaired daily functioning. In patients affected by chronic RLS/WED, a pharmacological therapy is recommended. International guidelines suggest to start the treatment with a α2δ calcium channel ligand in most cases, unless contraindicated.

AREAS COVERED

The present review is based on an extensive Internet and PubMed search from 1986 to 2024. Our purpose is to describe the absorption, distribution, metabolism, and toxicology (ADMET) of the α2δ ligands, with common consideration for the therapeutic class, specificities of different compounds, efficacy, and safety in relation to other treatment options.

EXPERT OPINION

α2δ ligands are quite similar in their ADMET profiles, sharing most of the pharmacokinetics and potential adverse effects. However, we highlight the linear kinetic of gabapentin enacarbil and pregabalin, differently from gabapentin. α2δ ligands are safe and effective for the treatment of RLS/WED. Additional benefits can be obtained in comorbid insomnia, chronic pain syndromes, history of impulse control disorder, and comorbid anxiety. The use of α2δ ligands is associated with poor risk of augmentation. We still need new long-term safe and effective treatments, which could be developed along with our knowledge of RLS/WED pathophysiology.

Restless Legs Syndrome in Children and Adolescents

Children with psychiatric comorbidities frequently are referred for evaluation of sleep complaints. Common sleep symptoms can include difficulty falling asleep, frequent nocturnal awakening, restless sleep, and symptoms of restless legs syndrome (RLS). The understanding of the sleep condition in relation to the psychiatric comorbidity often is a challenge to the physician and often sleep disorders remain undiagnosed, untreated, or undertreated. Restless legs syndrome has been associated with psychiatric comorbidities and with certain medications, such as antidepressants, antihistamines, and antipsychotics. This article reviews the presentation of RLS and restless sleep, the association with psychiatric comorbidities, and treatment options.

Sex-specific patterns of discomfort in patients with restless legs syndrome

STUDY OBJECTIVES

Sex differences in the prevalence of restless legs syndrome (RLS) have been reported, with a higher prevalence in women than in men. However, sex differences in clinical presentation remain unclear. We aimed to investigate the phenotypic differences in patients with RLS between sexes by comparing clinical presentations, iron status, polysomnographic parameters, and treatment.

METHODS

We retrospectively evaluated 614 patients (225 men, 389 women) diagnosed with RLS. To enhance the robustness of the study, an age-matched control group of 179 men and 286 women without sleep disorders was also included. Information on demographics and sleep-related questionnaires were collected. Iron status was evaluated using blood samples, and polysomnography was performed to evaluate periodic leg movements and comorbid sleep disorders.

RESULTS

Our analysis revealed no sex difference in the severity of RLS but a difference in the pattern of symptoms. Women had more frequent symptoms of pain and awakening during sleep, while men had more common motor symptoms (both self-reported symptoms and periodic leg movement on polysomnography). Women with RLS also had lower iron parameters and received more frequent iron supplementation therapy than men. In contrast to women with RLS, who presented higher sleep disturbances and depressive mood, men with RLS had a higher risk of comorbidities such as hypertension and cardiovascular disease. These sex differences were notably more pronounced than in the control group.

CONCLUSIONS

This study suggests that sex differences exist in RLS phenotypes, and clinicians should consider these differences for treatment.

CITATION

Kim J, Kim JR, Park HR, Joo EY. Sex-specific patterns of discomfort in patients with restless legs syndrome. J Clin Sleep Med. 2024;20(2):253-259.

Improvement of restless leg syndrome in maintenance hemodialysis patients with limb ischemic preconditioning: a single-center randomized controlled clinical trial

OBJECTIVE

This study evaluated the efficacy and safety of limb ischemic preconditioning (LIPC) in treating restless leg syndrome (RLS) in maintenance hemodialysis (MHD) patients.

METHODS

A total number of 45 patients participated in the study. They were randomly divided into LIPC group and control group. The LIPC was performed by inflating the limb ischemic preconditioning training device in the patient's thigh to 200 mmHg to create transient ischemia, whereas control group inflated the device to 20 mmHg. International Restless Legs Syndrome (IRLS), Clinical Global Impression Scale (CGI-S), and Medical Outputs Study Sleep Scale were employed to evaluate LIPC effectiveness. The primary endpoint was the 'rate of clinical improvement in RLS severity', defined as the percentage of patients who had an IRLS score decrease of ≥5 points in each group.

RESULTS

After intervention, the rate of clinical improvement in RLS severity was 56.5% in the LIPC group and 13.6% in the control group (13 (56.5) vs 3 (13.6), p = 0.003). In addition, the LIPC group's IRLS, CGI-S scores, the sleep disturbance and somnolence scores showed a significant downward trend compared to the control group (-5.5 ± 5.3 vs - 1.0 ± 3.8, p = 0.002; -1.7 ± 1.2 vs - 0.5 ± 1.4, p = 0.003; -15.5 ± 17.8 vs 3.7 ± 12.0, p < 0.001; -9.9 ± 18.8 vs - 2.4 ± 8.6, p = 0.003). During the study, there were no serious adverse event in any of the patients.

CONCLUSIONS

LIPC could be employed to effectively and safely alleviate the RLS symptoms in MHD patients.

Sleep related rhythmic movement disorder: phenotypic characteristics and treatment response in a paediatric cohort

OBJECTIVE

To describe phenotypic, polysomnographic characteristics, impact, and treatment response in children with sleep related rhythmic movement disorder (SR-RMD).

BACKGROUND

There is limited research on SR-RMD. We have developed a systematic clinical evaluation of children with SR-RMD to improve understanding and treatment.

METHODS

A retrospective chart review of 66 children at a UK tertiary hospital. Baseline assessment included validated screening questionnaires to study autism spectrum characteristics, general behaviour and sensory profile. A standardised questionnaire assessed impact on sleep quality and daytime wellbeing of child and family. Polysomnography data were collated.

RESULTS

Children were aged 0.9-16.3 years (78.8% male). 51.5% had a neurodevelopmental disorder, most commonly autism spectrum disorder. High rates of behavioural disturbance and sensory processing differences were reported, not confined to children with neurodevelopmental disorders. Parents reported concerns about risk of injury, loss of sleep and persistence into adulthood. Daytime wellbeing was affected in 72% of children and 75% of other family members. Only 31/48 children demonstrated rhythmic movements during video-polysomnography, occupying on average 6.1% of time in bed. Most clusters occurred in the settling period but also arose from N1, N2 and REM sleep and wake after sleep onset. Melatonin was prescribed to 52 children, all but one were extended-release preparations. 24/27 children with available data were reported to improve with melatonin.

CONCLUSIONS

SR-RMD places a significant burden on child and family wellbeing. Our novel findings of sensory processing differences in this population and parent reported therapeutic response to extended-release melatonin offer potential avenues for future research.

Nutrient insufficiencies and deficiencies involved in the pathogenesis of bruxism (Review)

Stress has been well-documented to have a significant role in the etiopathogenesis of bruxism. Activation of the hypothalamic-pituitary-adrenal axis (HPA) and subsequent release of corticosteroids lead to increased muscle activity. Neurological studies have demonstrated that chronic stress exposure induces neurodegeneration of important neuronal structures and destabilization of the mesocortical dopaminergic pathway. These disruptions impair the abilities to counteract the overactivity of the HPA axis and disinhibit involuntary muscle activity, while at the same time, there is activation of the amygdala. Recent evidence shows that overactivation of the amygdala under stressful stimuli causes rhythmic jaw muscle activity by over activating the mesencephalic and motor trigeminal nuclei. The present review aimed to discuss the negative effects of certain vitamin and mineral deficiencies, such as vitamin D, magnesium, and omega-3 fatty acids, on the central nervous system. It provides evidence on how such insufficiencies may increase stress sensitivity and neuromuscular excitability and thereby reduce the ability to effectively respond to the overactivation of the sympathetic nervous system, and also how stress can in turn lead to these insufficiencies. Finally, the positive effects of individualized supplementation are discussed in the context of diminishing anxiety and oxidative stress, neuroprotection and in the reversal of neurodegeneration, and also in alleviating/reducing neuromuscular symptoms.

Association of low serum ferritin levels with augmentation in patients with restless legs syndrome: A systematic review and meta-analysis

BACKGROUND

Augmentation of restless legs syndrome (RLS) is an iatrogenic side effect induced by dopaminergic agents, and it is a major cause of therapeutic failure. Iron deficiency is a risk factor for RLS, but its effects on the development of RLS augmentation are unclear. This meta-analysis aimed to elucidate the association between serum ferritin and RLS augmentation.

METHODS

We searched the PubMed, Cochrane Library, Embase, ClinicalKey, ScienceDirect, and ProQuest databases for studies comparing the serum ferritin levels of patients with augmented RLS and nonaugmented RLS. A meta-analysis based on a random-effects model was conducted. Levodopa equivalent dose (LED), International Restless Legs Study Group Severity Rating Scale (IRLS), and serum hemoglobin levels were also analyzed.

RESULTS

Six observational studies fulfilled the eligibility criteria of this meta-analysis. A total of 220 RLS patients with augmentation and 687 RLS patients without augmentation were included. The results revealed that augmented RLS was significantly associated with low serum ferritin levels (p = 0.002), high LEDs (p = 0.026), and nonsignificantly associated with high IRLS scores (p = 0.227).

CONCLUSIONS

A low serum ferritin level is associated with RLS augmentation. For patients with RLS who are iron deficient, iron supplements can not only relieve their fundamental RLS symptoms but also lower the risk of RLS augmentation. Moreover, non-dopminergic agents should be considered as the first-line treatment for patients with persistent low serum ferritin levels or those with moderate to severe RLS to prevent augmentation.

Evaluation and treatment approaches for neurological post-acute sequelae of COVID-19: A consensus statement and scoping review from the global COVID-19 neuro research coalition

Post-acute neurological sequelae of COVID-19 affect millions of people worldwide, yet little data is available to guide treatment strategies for the most common symptoms. We conducted a scoping review of PubMed/Medline from 1/1/2020-4/1/2023 to identify studies addressing diagnosis and treatment of the most common post-acute neurological sequelae of COVID-19 including: cognitive impairment, sleep disorders, headache, dizziness/lightheadedness, fatigue, weakness, numbness/pain, anxiety, depression and post-traumatic stress disorder. Utilizing the available literature and international disease-specific society guidelines, we constructed symptom-based differential diagnoses, evaluation and management paradigms. This pragmatic, evidence-based consensus document may serve as a guide for a holistic approach to post-COVID neurological care and will complement future clinical trials by outlining best practices in the evaluation and treatment of post-acute neurological signs/symptoms.

Restless legs syndrome: From clinic to personalized medicine

Restless legs syndrome (RLS) is a common neurological sensorimotor disorder that impairs sleep, mood and quality of life. RLS is defined by an urge to move the legs at rest that increases in the evening and at night, and is frequently associated with metabolic and cardiovascular diseases. Symptoms frequency, age at RLS onset, severity, familial history and consequences of RLS vary widely between patients. A genetic susceptibility, iron deficiency, dopamine deregulation, and possible hypo-adenosinergic state may play a role in the pathophysiology of RLS. Polysomnographic recordings found often periodic leg movements during sleep and wakefulness in patients with RLS. RLS can be classified as primary or comorbid with major diseases: iron deficiency, renal, neurological, rheumatological and lung diseases. First-line treatments are low-dose dopamine agonists, and alpha-2-delta ligands depending on the clinical context, and second/third line opiates for pharmacoresistant forms of RLS. Augmentation syndrome is a serious complication of dopamine agonists and should be prevented by using the recommended low dose. Despite an increase in knowledge, RLS is still underdiagnosed, poorly recognized, resulting in substantial individual health burden and socioeconomic coast, and education is urgently needed to increase awareness of this disabling disorder.