1
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Safarpour Y, Vaziri ND, Jabbari B. Restless Legs Syndrome in Chronic Kidney Disease- a Systematic Review. Tremor Other Hyperkinet Mov (N Y) 2023; 13:10. [PMID: 37008995 PMCID: PMC10064886 DOI: 10.5334/tohm.752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/07/2023] [Indexed: 03/31/2023] Open
Abstract
Objectives The objective of this review is to provide updated information on the epidemiology, correlating factors and treatment of chronic kidney disease associated restless legs syndrome (CKD-A-RLS) in both adult and pediatric population. Materials and Methods We have reviewed the Medline search and Google Scholar search up to May 2022, using key words restless legs syndrome, chronic kidney disease and hemodialysis and kidney transplant. The reviewed articles were studied for epidemiology, correlating factors, as well as pharmacologic and non-pharmacologic treatment options. Results Our search revealed 175 articles, 111 were clinical trials or cross- sectional studies and 64 were review articles. All 111 articles were retrieved and studied in detail. Of these, 105 focused on adults and 6 on children. A majority of studies on dialysis patients reported a prevalence between 15-30%, which is notably higher than prevalence of RLS in general population (5-10%). The correlation between presence of CKD-A-RLS with age, gender, abnormalities of hemogram, iron, ferritin, serum lipids, electrolytes and parathyroid hormones were also reviewed. The results were inconsistent and controversial. Limited studies have reported on the treatment of CKD-A-RLS. Non-pharmacological treatment focused on the effect(s) of exercise, acupuncture, massage with different oils and infra-red light whereas, pharmacologic treatment options include the effects of dopaminergic drugs, Alpha2-Delta ligands (gabapentin and pregabalin), vitamins E and C, and intravenous iron infusion. Conclusion This updated review showed that RLS is two to three times more common in patients with CKD compared to the general population. More patients with CKD-A-RLS demonstrated increased mortality, increased incidence of cardiovascular accident, depression, insomnia and impaired quality of life than those with CKD without RLS. Dopaminergic drugs such as levodopa, ropinirole, pramipexole and rotigotine as well as calcium channel blockers (gabapentin and pregabalin) are helpful for treatment of RLS. High quality studies with these agents are currently underway and hopefully confirm the efficacy and practicality of using these drugs in CKD-A-RLS. Some studies have shown that aerobic exercise and massage with lavender oil can improve symptoms of CKD-A- RLS suggesting that these measures can be useful as adjunct therapy.
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2
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Prasad B, Gagarinova M, Sharma A. Five Things to Know About Restless Legs Syndrome in Patients on Dialysis. Can J Kidney Health Dis 2023; 10:20543581231164275. [PMID: 36994129 PMCID: PMC10041586 DOI: 10.1177/20543581231164275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Affiliation(s)
- Bhanu Prasad
- Division of Nephrology, Department of Medicine, Regina General Hospital, SK, Canada
- Bhanu Prasad, Division of Nephrology, Department of Medicine, Regina General Hospital, 1440, 14th Avenue, Regina, SK S4P 0W5, Canada.
| | | | - Aditi Sharma
- Dr. T Bhanu Prasad Medical Prof Corp, Regina, SK, Canada
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3
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Diaz S, Abad K, Patel SR, Unruh ML. Emerging Treatments for Insomnia, Sleep Apnea, and Restless Leg Syndrome Among Dialysis Patients. Semin Nephrol 2022; 41:526-533. [PMID: 34973697 DOI: 10.1016/j.semnephrol.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Sleep disturbances are highly prevalent in patients with predialysis chronic kidney disease, end-stage kidney disease, and after a kidney transplant. They contribute to impairment in daily function and are associated with a high burden of physical and psychiatric symptoms, decreased quality of life, and increased morbidity and mortality. Sleep disturbances also may precipitate and accelerate kidney disease progression. They often evolve across the spectrum of kidney dysfunction and may persist or re-emerge in kidney transplant recipients. Investigation into the multifaceted and dynamic relationships between sleep disturbance and chronic kidney disease requires consideration of myriad contributors including the progression of kidney disease itself, the role of treatment via dialysis and kidney transplant, psychosocial factors, and underlying sleep disorders. Despite sleep disturbance being identified as a priority to address by patients and caregivers, sleep disorders including insomnia, sleep apnea, and restless leg syndrome remain under-recognized and undertreated, and innovation in their management remains modest. In this article, we review the relationships between sleep disturbance and kidney disease, the impact of sleep disturbance and sleep disorders on symptom burden and mental health, and treatment opportunities that may address overlapping symptoms across the spectrum of kidney disease and that could improve patient-related and clinical outcomes.
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Affiliation(s)
- Shanna Diaz
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM
| | - Kashif Abad
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM
| | - Sanjay R Patel
- Pulmonary, Sleep and Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mark L Unruh
- Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Nephrology Section, New Mexico Veterans Hospital, Albuquerque, NM.
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4
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So S, Brennan FP, Brown MA. Cognitive Biases in Medicine: The Potential Impact on the Diagnosis of Restless Legs Syndrome in Chronic Kidney Disease. J Pain Symptom Manage 2021; 61:870-877. [PMID: 33035652 DOI: 10.1016/j.jpainsymman.2020.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 11/12/2022]
Affiliation(s)
- Sarah So
- Department of Palliative Care, St George Hospital, Kogarah, Sydney, Australia; St George & Sutherland Clinical Schools, University of NSW, Sydney, New South Wales, Australia.
| | - Frank P Brennan
- Department of Palliative Care, St George Hospital, Kogarah, Sydney, Australia; Department of Renal Medicine, St George Hospital, Kogarah, Sydney, Australia; St George & Sutherland Clinical Schools, University of NSW, Sydney, New South Wales, Australia
| | - Mark A Brown
- Department of Renal Medicine, St George Hospital, Kogarah, Sydney, Australia; St George & Sutherland Clinical Schools, University of NSW, Sydney, New South Wales, Australia
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Abstract
Restless legs syndrome (RLS)/Willis-Ekbom disease is a neurologic disorder characterized by a strong desire to move when at rest (usually in the evening) and paraesthesia in their lower legs. The most widely used therapies for first-line treatment of RLS are dopaminergic drugs; however, their long-term use can lead to augmentation. α2δ Ligands, opioids, iron, glutamatergic drugs, adenosine, and sleep aids have been investigated as alternatives. The pathogenesis of RLS is not well understood. Despite the efficacy of dopaminergic drugs in the treatment of this disorder, unlike in Parkinson’s disease dopaminergic cell loss in the substantia nigra has not been observed in RLS. The etiology of RLS is likely complex, involving multiple neural pathways. RLS-related genes identified in genome-wide association studies can provide insight into the mechanistic basis and pathophysiology of RLS. Here we review the current treatments and knowledge of the mechanisms underlying RLS.
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Affiliation(s)
- Qing Lv
- Department of Neurology, TongRen Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xinlin Wang
- Department of Neurology, TongRen Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Tetsuya Asakawa
- Department of Neurosurgery, Hamamatsu University School of Medicine, Handayama, 1-20-1, Higashi-ku, Hamamatsucity, Shizuoka 431-3192, Japan
| | - Xiao Ping Wang
- Department of Neurology, TongRen Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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6
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Abstract
Restless legs syndrome (RLS) is characterized by an uncomfortable urge to move the legs while at rest, relief upon movement or getting up to walk, and worsened symptom severity at night. RLS may be primary (idiopathic) or secondary to pregnancy or a variety of systemic disorders, especially iron deficiency, and chronic renal insufficiency. Genetic predisposition with a family history is common. The pathogenesis of RLS remains unclear but is likely to involve central nervous system dopaminergic dysfunction, as well as other, undefined contributing mechanisms. Evaluation begins with a thorough history and examination, and iron measures, including ferritin and transferrin saturation, should be checked at presentation and with worsened symptoms, especially when augmentation develops. Augmentation is characterized by more intense symptom severity, earlier symptom occurrence, and often, symptom spread from the legs to the arms or other body regions. Some people with RLS have adequate symptom control with non-pharmacological measures such as massage or temperate baths. First-line management options include iron-replacement therapy in those with evidence for reduced body-iron stores or, alternatively, with prescribed gabapentin or pregabalin, and dopamine agonists such as pramipexole, ropinirole, and rotigotine. Second-line therapies include intravenous iron infusion in those who are intolerant of oral iron and/or those having augmentation with intense, severe RLS symptoms, and opioids including tramadol, oxycodone, and methadone. RLS significantly impacts patients' quality of life and remains a therapeutic area sorely in need of innovation and a further pipeline of new, biologically informed therapies.
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Affiliation(s)
- Thomas R Gossard
- Mayo Center for Sleep Medicine, 200 First Street SW, Rochester, MN, 55905, USA
| | | | | | - Erik K St Louis
- Mayo Center for Sleep Medicine, 200 First Street SW, Rochester, MN, 55905, USA.
- Departments of Neurology and Clinical and Translational Research, Mayo Clinic Southwest Wisconsin, La Crosse, Wisconsin, USA.
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7
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Collister D, Pohl K, Herrington G, Lee SF, Rabbat C, Tennankore K, Zimmermann D, Tangri N, Wald R, Manns B, Suri RS, Nadeau-Fredette AC, Goupil R, Silver SA, Walsh M. The DIalysis Symptom COntrol-Restless Legs Syndrome (DISCO-RLS) Trial: A Protocol for a Randomized, Crossover, Placebo-Controlled Blinded Trial. Can J Kidney Health Dis 2020; 7:2054358120968959. [PMID: 33294203 PMCID: PMC7705292 DOI: 10.1177/2054358120968959] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/11/2020] [Indexed: 11/17/2022] Open
Abstract
Background Restless legs syndrome (RLS) affects approximately 30% of patients with end-stage kidney disease and is associated with impaired sleep and health-related quality of life. Medications used to treat RLS in patients receiving dialysis may have an increased risk of adverse events with dose titration, and residual RLS symptoms are common despite the use of effective treatments. Randomized controlled trials of monotherapy and combination pharmacologic therapy for RLS in hemodialysis are needed. Objective To perform a randomized, crossover, placebo-controlled blinded trial of pharmacologic therapy for RLS in hemodialysis. Design/setting The DIalysis Symptom COntrol-Restless Legs Syndrome (DISCO-RLS) trial is a randomized, crossover, placebo-controlled blinded trial of fixed low-dose pharmacologic therapy in patients receiving hemodialysis in 10 centers across Canada. It uses patient partners in its design, conduct, and reporting. Participants Adults receiving thrice-weekly hemodialysis for at least 3 months with RLS of at least mild symptoms defined International Restless Legs Syndrome Study Group Rating Scale (IRLS) of 10 or more will enter a double placebo run-in period to exclude nonadherent participants and those unable to tolerate double placebo. Seventy-two participants who completed the run-in period will be randomized to 1 of 8 treatment sequences based on modeling with 4 treatment periods. Methods Each treatment period lasts 4 weeks and consists of ropinirole 0.5 mg daily and gabapentin 100 mg daily, both together or neither with a double dummy placebo control for each treatment. The primary outcome is the difference in change scores of the IRLS between study treatments. Secondary outcomes are the differences in change scores of the Restless Legs Syndrome-6 Scale, patient global impression, 5-level EQ-5D version, and safety outcomes. Results This randomized, crossover, placebo-controlled blinded trial will evaluate the efficacy and safety of fixed low-dose combination of ropinirole and gabapentin in patients receiving hemodialysis with RLS. Limitations Patients with chronic kidney disease not on dialysis, kidney transplant recipients and those receiving peritoneal dialysis or home hemodialysis are not included. The intervention's long term safety and efficacy including the risk of augmentation is not captured. Conclusion This randomized crossover placebo controlled blinded trial will evaluate the efficacy and safety of fixed low-dose combination ropinirole and gabapentin in patients receiving hemodialysis with RLS. Trial Registration ClinicalTrials.gov (NCT03806530).
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Affiliation(s)
- David Collister
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kayla Pohl
- Population Health Research Institute, Hamilton, ON, Canada
| | - Gwen Herrington
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD), Vancouver, BC, Canada
| | - Shun Fu Lee
- Population Health Research Institute, Hamilton, ON, Canada
| | - Christian Rabbat
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Navdeep Tangri
- Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Ron Wald
- Department of Medicine, University of Toronto, ON, Canada
| | - Braden Manns
- Department of Medicine and Community Health Sciences, University of Calgary, AB, Canada
| | - Rita S Suri
- Department of Medicine, McGill University, Montréal, QC, Canada.,Centre de Recherche, Université de Montréal, QC, Canada
| | | | - Remi Goupil
- Faculté de Médecine, Université de Montréal, QC, Canada
| | - Samuel A Silver
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Michael Walsh
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
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8
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Safarpour Y, Vaziri ND, Jabbari B. Movement Disorders in Chronic Kidney Disease - A Descriptive Review. J Stroke Cerebrovasc Dis 2020; 30:105408. [PMID: 33139171 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105408] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/19/2020] [Accepted: 10/12/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES The objective of this study is to describe the mechanism of damage to subcortical structures in chronic kidney disease (CKD) and to describe the range of movement disorders associated with CKD. MATERIALS AND METHODS We have reviewed the Medline literature up to January of 2020 using key words movement disorders and chronic kidney disease. The reviewed articles were studied for mechanisms of subcortical damage in CKD as well as type of the reported movements, their frequency and updated treatment. RESULTS The search revealed 183 articles most of them dealing with restless legs syndrome. The damage to basal ganglia in CKD resulted from several mechanisms including accumulation of nitro tyrosine caused by reactive oxygen species and action of uremic toxins leading to endothelial damage and dysfunction of blood-brain barrier. Involuntary movements in CKD include restless legs syndrome (RLS), myoclonus, asterixis, dystonia, chorea, tremor, and Parkinsonism. CONCLUSIONS Chronic kidney disease can cause several abnormal involuntary movements via damaging basal ganglia and subcortical structures. The most common movement disorders in CKD are RLS, myoclonus and asterixis. Restless legs syndrome and myoclonus when severe, need and respond to treatment. Movement disorders in CKD improve with improvement of kidney function.
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Affiliation(s)
- Yasaman Safarpour
- Department of Medicine. University of California Riverside, School of Medicine, United States.
| | - Nosratola D Vaziri
- Division of Nephrology, Department of Medicine, University of California Irvine, United States.
| | - Bahman Jabbari
- Division of Movement Disorders, Department of Neurology, Yale University School of Medicine, United States.
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9
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Samaha D, Kandiah T, Zimmerman D. Cannabis Use for Restless Legs Syndrome and Uremic Pruritus in in patients treated with maintenance dialysis: A Survey. Can J Kidney Health Dis 2020; 7:2054358120954944. [PMID: 32963792 PMCID: PMC7488602 DOI: 10.1177/2054358120954944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/29/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Restless legs syndrome (RLS) and uremic pruritus reduce the quality of life
in patients with end-stage kidney disease (ESKD) and current treatments are
often insufficient. There is an increasing interest in using cannabinoids
for symptom management, and preliminary evidence suggests cannabinoids may
help alleviate RLS and pruritus. Objectives: (1) To assess the frequency and severity of RLS and pruritus in our ESKD
population with the current treatment options, (2) to estimate patient use
of cannabinoids for these symptoms, and (3) to determine interest in
participating in future trials to treat RLS and/or pruritus. Design: Survey. Patients: Adult prevalent patients with ESKD treated with dialysis at the Ottawa
Hospital. Measurements: International RLS Study Group Rating Scale and visual analogue scale for
symptom severity of RLS and pruritus, respectively. Methods: Eligible patients with ESKD treated at the Ottawa Hospital were invited to
complete a survey to identify symptoms and severity of RLS and pruritus
using validated scales, cannabis use for management, and interest in future
trials. Basic demographic statistics to describe the study population and
results were used. Results: Sixty-nine percent (192 of 277) of eligible patients completed the surveys,
35 declined participation, and 50 surveys were not returned. Eighty-six
(45%) and 129 patients (67%) reported symptoms of RLS and pruritus,
respectively. Only 18 previously symptomatic patients were relieved with
current treatment. Fifteen patients reported cannabis use for symptoms; 9
noted improvement. Most (>2 of 3) symptomatic patients were interested in
participating in a future trial. Limitations: Single-center study in a tertiary-care hospital in Canada limiting
generalizability. Quoted prevalence of symptoms is dependent on survey
return. Conclusions: A large proportion of ESKD patients suffer from RLS and/or pruritus, most of
which are not relieved by existing treatments. Few patients reported trying
cannabis to decrease their symptoms despite legalization. This study
confirms strong patient interest for future trials regarding cannabis for
symptom relief. Trial Registration: Not applicable.
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Affiliation(s)
- Daniel Samaha
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, ON, Canada.,Kidney Research Centre, Ottawa Hospital Research Institute, ON, Canada
| | | | - Deborah Zimmerman
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, ON, Canada.,Kidney Research Centre, Ottawa Hospital Research Institute, ON, Canada
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10
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Salib M, Memon AN, Gowda AS, Rallabhandi B, Bidika E, Fayyaz H, Cancarevic I. Dialysis Patients With Restless Leg Syndrome: Can We Relieve Their Suffering? Cureus 2020; 12:e10053. [PMID: 32999776 PMCID: PMC7520405 DOI: 10.7759/cureus.10053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Restless leg syndrome (RLS), also called Willis Ekbom disease, can be described as an unpleasant feeling that intensely urges the patients to move their lower limbs. RLS is classified into primary and secondary. It is one of the common complications in hemodialysis patients, and it impairs patients’ quality of life. Unfortunately, it is an underdiagnosed and undertreated disorder. In this review article, we performed a literature search using the PubMed database to compare different treatment modalities for RLS in patients with end-stage renal disease (ESRD) on regular hemodialysis. Many of the non-pharmacologic modalities of treatment are cost-effective and safer than pharmacologic therapy. Given the small sample size of the studies and short follow up duration, we should consider conducting studies on a larger number of patients and for longer periods of time to assess the efficacy and safety of different treatment patterns for RLS in hemodialysis patients. We hope to raise awareness about this neurologic condition in hemodialysis patients.
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Affiliation(s)
- Marina Salib
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Areeba N Memon
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Asavari S Gowda
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bhavana Rallabhandi
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Erjola Bidika
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Hafsa Fayyaz
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ivan Cancarevic
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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11
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Affiliation(s)
- Jackson Tan
- Renal Unit Leeds General Infirmary Leeds, England, UK
| | - Axel Derwa
- Renal Unit Leeds General Infirmary Leeds, England, UK
| | - Vinod Sanu
- Renal Unit Leeds General Infirmary Leeds, England, UK
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12
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Huang CW, Lee MJ, Wang LJ, Lee PT, Tu YK, Hsu CW, Lin PY. Comparative efficacy and acceptability of treatments for restless legs syndrome in end-stage renal disease: a systematic review and network meta-analysis. Nephrol Dial Transplant 2019; 35:1609-1618. [DOI: 10.1093/ndt/gfz097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022] Open
Abstract
Abstract
Background
Restless legs syndrome (RLS) is common in end-stage renal disease (ESRD) patients and impairs health and quality of life significantly. However, the optimal treatment of RLS in ESRD patients is uncertain and less studied compared with idiopathic RLS patients.
Methods
We conducted a systematic review and network meta-analysis to compare the efficacy and acceptability of treatments for RLS in ESRD patients. Randomized controlled trials (RCTs) by February 2019 in the PubMed, Cochrane Library, Embase and ClinicalTrials.gov were reviewed. RLS severity reduction was treated as treatment efficacy, and adverse events were treated as acceptable. Both outcomes were appraised using a random effects model expressed as standardized mean differences and odds ratios with 95% confidence intervals (CIs), respectively, and were ranked using surface under the cumulative ranking curve (SUCRA) probabilities to obtain a hierarchy of interventions.
Results
A total of 12 RCTs were included, comprising 9 interventions and 498 participants. All the interventions significantly improved RLS severity without critical side effects compared with placebo. Gabapentin achieved the greatest decrease of RLS severity [standardized mean difference (SMD) = 1.95, 95% CI 0.81–3.09 (SUCRA: 79.3%)], despite its frequent adverse events [SMD = 0.18, 95% CI 0.02–1.50 (19.9%)]. The combination therapy of exercise plus dopamine agonist had better efficacy [SMD = 1.60, 95% CI 0.08–3.12 (59.8%)] and acceptability [SMD = 1.41, 95% CI 0.01–142.53 (63.9%)] compared with that of vitamin C plus vitamin E [SMD = 1.50, 95% CI 0.47–2.54 (56.6%); SMD = 0.32, 95% CI 0.04–2.86 (32.5%)].
Conclusions
This network meta-analysis supports that gabapentin is the most effective treatment for RLS in ESRD patients. Exercise plus dopamine agonist is a favorable combination therapy concerning side effects. Future large RCTs with long-term treatment outcomes are necessary.
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Affiliation(s)
- Chien-Wei Huang
- Department of Medicine, Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Min-Jing Lee
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Liang-Jen Wang
- Department of Child and Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Po-Tsang Lee
- Department of Medicine, Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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13
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Peckham AM, Evoy KE, Ochs L, Covvey JR. Gabapentin for Off-Label Use: Evidence-Based or Cause for Concern? Subst Abuse 2018; 12:1178221818801311. [PMID: 30262984 PMCID: PMC6153543 DOI: 10.1177/1178221818801311] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/09/2018] [Indexed: 01/15/2023]
Abstract
Gabapentin is widely used in the United States for a number of off-label indications, often as an alternative to opioid therapy. Increasing evidence has emerged suggesting that gabapentin may not be as benign as once thought and may be associated with substance abuse in concert with opioids. With concerns for safety mounting, it is prudent to examine the efficacy of gabapentin across its many uses to understand the risk-benefit balance. Reviews on off-label indications such as migraine, fibromyalgia, mental illness, and substance dependence have found modest to no effect on relevant clinical outcomes. This high-quality evidence has often been overshadowed by uncontrolled studies and limited case reports. Furthermore, the involvement of gabapentin in questionable marketing schemes further calls its use into question. Overall, clinicians should exercise rigorous appraisal of the available evidence for a given indication, and researchers should conduct larger, higher-quality studies to better assess the efficacy of gabapentin for many of its off-label uses.
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Affiliation(s)
- Alyssa M Peckham
- School of Pharmacy, Northeastern University, Boston, MA, USA
- Substance Use Disorders Initiative, Massachusetts General Hospital, Boston, MA, USA
| | - Kirk E Evoy
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- School of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
- Southeast Clinic, University Health System, San Antonio, TX, USA
| | - Leslie Ochs
- Department of Pharmacy Practice, College of Pharmacy, University of New England, Portland, ME, USA
| | - Jordan R Covvey
- Division of Pharmaceutical, Administrative and Social Sciences, School of Pharmacy, Duquesne University, Pittsburgh, PA, USA
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14
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Ishida JH, McCulloch CE, Steinman MA, Grimes BA, Johansen KL. Gabapentin and Pregabalin Use and Association with Adverse Outcomes among Hemodialysis Patients. J Am Soc Nephrol 2018; 29:1970-1978. [PMID: 29871945 DOI: 10.1681/asn.2018010096] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/23/2018] [Indexed: 12/21/2022] Open
Abstract
Background Gabapentin and pregabalin are used to manage neuropathic pain, pruritus, and restless legs syndrome in patients on hemodialysis. These patients may be especially predisposed to complications related to these agents, which are renally cleared, but data regarding the risk thereof are lacking.Methods From the US Renal Data System, we identified 140,899 Medicare-covered adults receiving hemodialysis with Part D coverage in 2011. Using Cox regression models in which we adjusted for demographics, comorbidities, duration of exposure, number of medications, and use of potentially confounding concomitant medications, we investigated the association between gabapentin and pregabalin, modeled as separate time-varying exposures, and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture. We evaluated risk according to daily dose categories: gabapentin (>0-100, >100-200, >200-300, and >300 mg) and pregabalin (>0-100 and >100 mg).Results In 2011, 19% and 4% of patients received gabapentin and pregabalin, respectively. Sixty-eight percent of gabapentin or pregabalin users had a diagnosis of neuropathic pain, pruritus, or restless legs syndrome. Gabapentin was associated with 50%, 55%, and 38% higher hazards of altered mental status, fall, and fracture, respectively, in the highest dose category, but even lower dosing was associated with a higher hazard of altered mental status (31%-41%) and fall (26%-30%). Pregabalin was associated with up to 51% and 68% higher hazards of altered mental status and fall, respectively.Conclusions Gabapentin and pregabalin should be used judiciously in patients on hemodialysis, and research to identify the most optimal dosing is warranted.
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Affiliation(s)
- Julie H Ishida
- Departments of Medicine and .,Division of Nephrology, San Francisco Veterans Affairs Medical Center, San Francisco, California; and
| | - Charles E McCulloch
- Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Barbara A Grimes
- Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Kirsten L Johansen
- Departments of Medicine and.,Division of Nephrology, San Francisco Veterans Affairs Medical Center, San Francisco, California; and.,Epidemiology and Biostatistics, University of California, San Francisco, California
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15
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Winkelmann J, Allen RP, Högl B, Inoue Y, Oertel W, Salminen AV, Winkelman JW, Trenkwalder C, Sampaio C. Treatment of restless legs syndrome: Evidence-based review and implications for clinical practice (Revised 2017)§. Mov Disord 2018; 33:1077-1091. [DOI: 10.1002/mds.27260] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 10/25/2017] [Accepted: 10/27/2017] [Indexed: 12/30/2022] Open
Affiliation(s)
- Juliane Winkelmann
- Institute of Neurogenomics; Helmholtz Zentrum München; Munich Germany
- Department of Neurology and Department of Human Genetics; Klinikum rechts der Isar, Technical University; Munich Germany
- Munich Cluster for Systems Neurology (SyNergy); Munich Germany
| | - Richard P. Allen
- Sleep Disorders Center; Johns Hopkins Bayview Medical Center; Baltimore Maryland USA
- Department of Neurology; Johns Hopkins University; Baltimore Maryland USA
| | - Birgit Högl
- Department of Neurology; Medical University of Innsbruck; Innsbruck Austria
| | - Yuichi Inoue
- Japan Somnology Center; Neuropsychiatric Research Institute; Tokyo Japan
- Department of Somnology; Tokyo Medical University; Tokyo Japan
| | - Wolfgang Oertel
- Department of Neurology; Philipps-Universität Marburg; Marburg Germany
| | - Aaro V. Salminen
- Institute of Neurogenomics; Helmholtz Zentrum München; Munich Germany
- Department of Neurology; Philipps-Universität Marburg; Marburg Germany
| | - John W. Winkelman
- Harvard Medical School; Boston Massachusetts USA
- Departments of Psychiatry and Neurology; Massachusetts General Hospital; Boston Massachusetts USA
| | - Claudia Trenkwalder
- Department of Neurosurgery; University Medical Center; Goettingen Germany
- Paracelsus-Elena Hospital; Kassel Germany
| | - Cristina Sampaio
- CHDI Foundation, Princeton, Princeton, NJ, USA, and the Instituto de Medicina Molecular; University of Lisbon; Lisbon Portugal
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Abstract
Poor sleep and sleep-related breathing disorders are common in patients with end-stage renal disease (ESRD) but are often unrecognized and undertreated. Sleep disorders are known negative prognostic factors for morbidity and mortality. The most frequent sleep disorders seen in patients with ESRD are conditioned insomnia, excessive daytime sleepiness, obstructive or central sleep apnea (SA), as well as restless legs syndrome (RLS) and periodic limb movement disorder (PLMD). Several uremic and nonuremic factors are thought to participate in the pathogenesis of sleep disorders in patients with ESRD. The therapy of sleeping disorders includes nonpharmacological and pharmacological measures that can improve the functionality and quality of life in patients with ESRD.
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Affiliation(s)
- G.C. Kosmadakis
- “John Walls” Renal Unit, Leicester General Hospital, Leicester - UK
| | - J.F. Medcalf
- “John Walls” Renal Unit, Leicester General Hospital, Leicester - UK
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17
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Abstract
Restless legs syndrome (RLS) is a common neurological movement disorder, characterized by restless and unpleasant sensations in the deep inside of legs. The symptoms of RLS are less noticeable during daytime, but more prevalent at night. Therefore, the disorder can induce low quality of life, insomnia, and impairment of daytime activity. RLS in end-stage renal disease (ESRD) patients is especially problematic due to premature discontinuation of dialysis and increased mortality. The prevalence of RLS among dialysis patients is much higher compared to the prevalence of the same disorder in patients with normal renal functions. Even though there are recommended treatment guidelines for the general population established by Medical Advisory Board of the RLS foundation, which include the use of dopamine agonists, levodopa, gabapentin, benzodiazepines, and opioids, limited information is available on the effects of these therapies in ESRD patients. Since the existing clinical data were extrapolated from small sample sizes in short-term clinical trials, further clinical studies are still needed to better assess the efficacy, safety, and tolerability of these medications in patients with ESRD.
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Abstract
BACKGROUND Restless legs syndrome (RLS) is defined as the spontaneous movement of the limbs (mainly legs) associated with unpleasant, sometimes painful sensation which is relieved by moving the affected limb. Prevalence of RLS among people on dialysis has been estimated between 6.6% and 80%. RLS symptoms contribute to impaired quality of life and people with RLS are shown to have increased cardiovascular morbidity and mortality.Various pharmacological and non-pharmacological interventions have been used to treat primary RLS. However, the evidence for use of these interventions in people with chronic kidney disease (CKD) is not well established. The agents used in the treatment of primary RLS may be limited by the side effects in people with CKD due to increased comorbidity and altered drug pharmacokinetics. OBJECTIVES The aim of this review was to critically look at the benefits, efficacy and safety of various treatment options used in the treatment of RLS in people with CKD and those undergoing renal replacement therapy (RRT). We aimed to define different group characteristics based on CKD stage to assess the applicability of a particular intervention to an individual patient. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 12 January 2016 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCT) and quasi-RCTs that assessed the efficacy of an intervention for RLS in adults with CKD were eligible for inclusion. Studies investigating idiopathic RLS or RLS secondary to other causes were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility and conducted risk of bias evaluation. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS We included nine studies enrolling 220 dialysis participants. Seven studies were deemed to have moderate to high risk of bias. All studies were small in size and had a short follow-up period (two to six months). Studies evaluated the effects of six different interventions against placebo or standard treatment. The interventions studied included aerobic resistance exercise, gabapentin, ropinirole, levodopa, iron dextran, and vitamins C and E (individually and in combination).Aerobic resistance exercise showed a significant reduction in severity of RLS compared to no exercise (2 studies, 48 participants: MD -7.56, 95% CI -14.20 to -0.93; I2 = 65%), and when compared to exercise with no resistance (1 study, 24 participants: MD -11.10, 95% CI -17.11 to -5.09), however there was no significant reduction when compared to ropinirole (1 study, 22 participants): MD -0.55, 95% CI -6.41 to 5.31). There were no significant differences between aerobic resistance exercise and either no exercise or ropinirole in the physical or mental component summary scores (using the SF-36 form). Improvement in sleep quality varied. There was no significant difference in subjective sleep quality between exercise and no exercise; however one study reported a significant improvement with ropinirole compared to resistance exercise (MD 3.71, 95% CI 0.89 to 6.53). Using the Epworth Sleepiness Scale there were no significant differences between resistance exercise and no exercise, ropinirole, or exercise with no resistance. Two studies reported there were no adverse events and one study did not mention if there were any adverse events. In one study, one patient in each group dropped out but the reason for dropout was not reported. Two studies reported no adverse events and one study did not report adverse events.Gabapentin was associated with reduced RLS severity when compared to placebo or levodopa, and there was a significant improvement in sleep quality, latency and disturbance reported in one study when compared to levodopa. Three patients dropped out due to lethargy (2 patients), and drowsiness, syncope and fatigue (1 patient).Because of a short duration of action, rebound and augmentation were noted with levodopa treatment even though it conferred some benefit in reducing the symptoms of RLS. Reported adverse events were severe vomiting, agitation after caffeine intake, headaches, dry mouth, and gastrointestinal symptoms.One study (25 participants) reported iron dextran reduced the severity of RLS at weeks one and two, but not at week four. Vitamins C, E and C plus E (1 study, 60 participants) helped the symptoms of RLS with minimal side effects (nausea and dyspepsia) but more evidence is needed before any conclusions can be drawn. AUTHORS' CONCLUSIONS Given the small size of the studies and short follow-up, it can only be concluded that pharmacological interventions and intra-dialytic exercise programs have uncertain effects on RLS in haemodialysis patients. There have been no studies performed in non-dialysis CKD, peritoneal dialysis patients, or kidney transplant recipients. Further studies are warranted before any conclusions can be drawn. Aerobic resistance exercise and ropinirole may be suitable interventions for further evaluation.
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Affiliation(s)
- Seerapani Gopaluni
- Cambridge University Hospitals NHS Foundation TrustDepartment of NephrologyHills RoadCambridgeUKCB2 0QQ
- Oxford Kidney Unit, Churchill HospitalDepartment of Renal MedicineOxfordOxfordshireUKOX3 7LJ
| | - Mohamed Sherif
- Oxford Kidney Unit, Churchill HospitalDepartment of Renal MedicineOxfordOxfordshireUKOX3 7LJ
| | - Naim A Ahmadouk
- Buckinghamshire Hospitals NHS TrustDepartment of MedicineQueen Alexandra RdHigh WycombeUKHP11 2TT
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19
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Mackie SE, McHugh RK, McDermott K, Griffin ML, Winkelman JW, Weiss RD. Prevalence of restless legs syndrome during detoxification from alcohol and opioids. J Subst Abuse Treat 2016; 73:35-39. [PMID: 28017182 DOI: 10.1016/j.jsat.2016.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 09/18/2016] [Accepted: 10/03/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS Restless legs syndrome (RLS) is a movement disorder associated with adverse health outcomes and decreased quality of life. Small case series suggest that symptoms of RLS occur during opioid withdrawal. However, the prevalence is unknown. METHODS We conducted an observational study to determine the prevalence of RLS among inpatients patients receiving buprenorphine detoxification from opioids. To assess the specificity of RLS to opioid detoxification, we also evaluated patients receiving detoxification from alcohol as a comparison group. The diagnosis of RLS was established using a validated questionnaire. RESULTS The sample consisted of 124 adults with primary opioid use disorder and 180 with primary alcohol use disorder. In the total sample, 33.6% met a likely RLS diagnosis: 50.8% of those with opioid use disorder and 21.7% of those with alcohol use disorder (χ2 = 27.96[1,304] p < .001). In the logistic regression analysis controlling for socio-demographic and clinical variables, diagnosis of opioid use disorder was associated with more than twice the likelihood of RLS diagnosis (OR=2.05, 95% CI 1.09-3.88) relative to diagnosis of alcohol use disorder. CONCLUSIONS Approximately half of patients undergoing inpatient opioid detoxification exhibited the symptoms characteristic of RLS. We believe that these data support the existence of a secondary form of RLS associated with opioid withdrawal.
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Affiliation(s)
- Susan E Mackie
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115; Massachusetts General Hospital, 1 Bowdoin Square, 9th floor, Boston, MA 02114.
| | - R Kathryn McHugh
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115; McLean Hospital, 115 Mill St., Belmont, MA 02478
| | | | - Margaret L Griffin
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115; McLean Hospital, 115 Mill St., Belmont, MA 02478
| | - John W Winkelman
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115; Massachusetts General Hospital, 1 Bowdoin Square, 9th floor, Boston, MA 02114
| | - Roger D Weiss
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115; McLean Hospital, 115 Mill St., Belmont, MA 02478
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20
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Scherer JS, Combs SA, Brennan F. Sleep Disorders, Restless Legs Syndrome, and Uremic Pruritus: Diagnosis and Treatment of Common Symptoms in Dialysis Patients. Am J Kidney Dis 2016; 69:117-128. [PMID: 27693261 DOI: 10.1053/j.ajkd.2016.07.031] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 07/06/2016] [Indexed: 11/11/2022]
Abstract
Maintenance dialysis patients experience a high burden of physical and emotional symptoms that directly affect their quality of life and health care utilization. In this review, we specifically highlight common troublesome symptoms affecting dialysis patients: insomnia, restless legs syndrome, and uremic pruritus. Epidemiology, pathophysiology, and evidence-based current treatment are reviewed with the goal of providing a guide for diagnosis and treatment. Finally, we identify multiple additional areas of further study needed to improve symptom management in dialysis patients.
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Affiliation(s)
- Jennifer S Scherer
- Division of Palliative Care, NYU School of Medicine, New York, NY; Division of Nephrology, NYU School of Medicine, New York, NY.
| | - Sara A Combs
- Division of Nephrology, Department of Medicine, VA Eastern Colorado Health Care System, University of Colorado School of Medicine, Denver, CO; Division of Palliative Care, Department of Medicine, VA Eastern Colorado Health Care System, University of Colorado School of Medicine, Denver, CO
| | - Frank Brennan
- Department of Nephrology, St. George Hospital, Kogarah, New South Wales, Australia
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21
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Abstract
Symptoms of restless legs syndrome (RLS) are common in patients with chronic kidney disease (CKD) on dialysis; symptoms of RLS are estimated to affect up to 25% of patients on dialysis when the international RLS diagnostic criteria are applied. RLS is a neurologic disorder with a circadian rhythmicity characterized by an overwhelming urge to move the legs during rest, which can be relieved temporarily by movement. RLS has been associated with an increase in sleep disturbance, higher cardiovascular morbidity, decreased quality of life, and an increased risk of death in patients with CKD. Although the exact pathophysiology of RLS is unknown, it is thought to involve an imbalance in iron metabolism and dopamine neurotransmission in the brain. The symptoms of moderate to severe RLS can be treated with several pharmacologic agents; however, data specific to patients on dialysis with RLS are lacking. The purpose of this article is to examine the relationship between, and complications of, RLS and CKD both in dialysis and nondialysis patients, and discuss the treatment options for patients on dialysis with RLS.
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Affiliation(s)
- Marta Novak
- University Health Network, Department of Psychiatry, University of Toronto, Toronto, Canada; Institute of Behavioral Sciences, Semmelweis University, Budapest, Hungary.
| | - John W Winkelman
- Department of Psychiatry, Sleep Disorders Clinical Research Program, Massachusetts General Hospital, Boston, MA
| | - Mark Unruh
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM
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22
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Abstract
Restless legs syndrome (RLS) is a commonly occurring condition with a prevalence of approximately 10%. Women are more often affected than men. There is a primary and a secondary form. Secondary RLS is triggered by iron deficiency, severe renal insufficiency and many drugs and medications. The treatment for RLS is always symptomatic. In addition to treating associated diseases, dopaminergic therapy is paramount. Pharmacotherapy encompasses levodopa (L-dopa) and dopamine agonists, such as pramipexole, ropinirole and rotigotine. A serious complication of dopaminergic therapy is the so-called augmentation. In the case of insufficient efficacy, severe discomfort or augmentation, oxycodone/naloxone is now approved for the treatment of RLS.
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Affiliation(s)
- H Frohnhofen
- Zentrum für Altersmedizin, Kliniken Essen Mitte, Am Deimelsberg 34a, 45276, Essen, Deutschland,
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23
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Cheikh Hassan HI, Brennan F, Collett G, Josland EA, Brown MA. Efficacy and safety of gabapentin for uremic pruritus and restless legs syndrome in conservatively managed patients with chronic kidney disease. J Pain Symptom Manage 2015; 49:782-9. [PMID: 25220049 DOI: 10.1016/j.jpainsymman.2014.08.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Revised: 07/28/2014] [Accepted: 08/14/2014] [Indexed: 01/23/2023]
Abstract
CONTEXT Pruritus and restless legs syndrome (RLS) frequently affect patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD), impacting the quality of life. Gabapentin (1-aminomethyl cyclohexane acetic acid) alleviates these symptoms in hemodialysis (HD) patients, but data are lacking for patients on the conservative pathway. OBJECTIVES To determine the safety and effectiveness of gabapentin for pruritus or RLS in conservatively managed patients (n = 34) with CKD and ESKD. METHODS This was a single-center retrospective cohort study. We compared dosing and side effects in 34 CKD/ESKD patients with similar patients receiving HD (n = 15). RESULTS Forty-four percent of conservatively managed patients complained of RLS and/or pruritus; 18% were excluded for a nonuremic cause of symptom. Thirty-four patients were included in the final analysis. The most common starting daily dose of gabapentin was the equivalent of 50 mg (44.1%) or 100 mg (38.2%) daily, with the median daily dose of 100 mg (range 39-455 mg). Side effects occurred in 47% of patients, with 17% discontinuing gabapentin. Gabapentin reduced symptoms of pruritus (P < 0.001) and RLS (P < 0.05). There was no statistical difference when comparing HD and conservatively managed patients for daily starting dose (P = 0.88), median dose (P = 0.84), and final dose (P = 0.18). Patients conservatively managed were more likely to manifest side effects compared with HD patients (47.1% vs. 14.3%, P = 0.023). Dose was not found to be a factor associated with side effects in univariate analysis. CONCLUSION Gabapentin is a viable treatment for conservatively managed CKD and ESKD patients with pruritus and/or RLS, but side effects are common. Gabapentin should be used with caution although higher doses do not appear to be a factor associated with side effects.
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Affiliation(s)
- Hicham I Cheikh Hassan
- Department of Renal Medicine, St. George Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
| | - Frank Brennan
- Department of Renal Medicine, St. George Hospital, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia.
| | - Gemma Collett
- Department of Renal Medicine, St. George Hospital, Sydney, New South Wales, Australia
| | - Elizabeth A Josland
- Department of Renal Medicine, St. George Hospital, Sydney, New South Wales, Australia
| | - Mark A Brown
- Department of Renal Medicine, St. George Hospital, Sydney, New South Wales, Australia
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24
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Budhiraja R, Siddiqi TA, Quan SF. Sleep disorders in chronic obstructive pulmonary disease: etiology, impact, and management. J Clin Sleep Med 2015; 11:259-70. [PMID: 25700872 DOI: 10.5664/jcsm.4540] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 12/21/2014] [Indexed: 01/18/2023]
Abstract
ABSTRACT Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality and may frequently be complicated by sleep disorders. Insomnia and obstructive sleep apnea are commonly encountered in patients with COPD. Nocturnal hypoxemia is also prevalent in COPD may occur despite adequate awake oxygenation and can be especially severe in rapid eye movement sleep. Additionally, several factors--some of them unique to COPD--can contribute to sleep-related hypoventilation. Recognition of hypoventilation can be vital as supplemental oxygen therapy itself can acutely worsen hypoventilation and lead to disastrous consequences. Finally, accruing data establish an association between restless leg syndrome and COPD--an association that may be driven by hypoxemia and/or hypercapnia. Comorbid sleep disorders portend worse sleep quality, diminished quality of life, and multifarious other adverse consequences. The awareness and knowledge regarding sleep comorbidities in COPD has continued to evolve over past many years. There are still several lacunae, however, in our understanding of the etiologies, impact, and therapies of sleep disorders, specifically in patients with COPD. This review summarizes the latest concepts in prevalence, pathogenesis, diagnosis, and management of diverse sleep disorders in COPD.
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Affiliation(s)
- Rohit Budhiraja
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Tauseef A Siddiqi
- Division of Allergy, Critical Care, Pulmonary and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Stuart F Quan
- Division of Allergy, Critical Care, Pulmonary and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ.,Divisions of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Fröhlich AC, Eckeli AL, Bacelar A, Poyares D, Pachito DV, Stelzer FG, Coelho FMS, Rizzo GNV, Prado GFD, Sander HH, Goulart LI, Lucchesi LM, Gitai LLG, Prado LBFD, Ataíde-Junior L, Bezerra MLDS, Lopes MC, Trentin MM, Rodrigues RND, Hasan R, Alves RSC, Schönwald SV, Moraes WADS. Brazilian consensus on guidelines for diagnosis and treatment for restless legs syndrome. Arq Neuropsiquiatr 2015; 73:260-280. [PMID: 25807136 DOI: 10.1590/0004-282x20140239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 12/04/2014] [Indexed: 06/04/2023]
Abstract
The Consensus on restless legs syndrome is an effort of neurologists from several Brazilian states, which tirelessly reviewed the literature of recent years in search of evidence, both in regard to diagnosis and treatment, according to the Oxford Centre for Evidence-based Medicine.
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Affiliation(s)
| | - Alan Luiz Eckeli
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto, SP, Brazil
| | | | - Dalva Poyares
- Departamento de Psicobiologia, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | | | | | | | | | | | - Heidi Haueisen Sander
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto, SP, Brazil
| | | | | | | | | | | | | | - Maria Cecília Lopes
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
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26
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Affiliation(s)
- Sara N. Davison
- Division of Nephrology & Immunology; Department of Medicine; University of Alberta; Edmonton Alberta Canada
| | - Holly Koncicki
- Department of Geriatrics and Palliative Medicine; Department of Medicine; Icahn School of Medicine at Mount Sinai; New York City New York
| | - Frank Brennan
- Department of Palliative Care; St George Hospital; Sydney New South Wales Australia
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27
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Abstract
Gabapentin enacarbil is a prodrug of the anticonvulsant gabapentin. The efficacy and safety of gabapentin enacarbil for the treatment of moderate to severe primary restless legs syndrome (RLS) has been evaluated in several clinical trials in the United States and Japan. Although most clinical trials assessed gabapentin enacarbil at doses greater than 600 mg/day and demonstrated the overall safety and efficacy (defined as improvements in the coprimary endpoints of the international RLS rating scale [IRLS] total score and Clinical Global Impression-Improvement response), the US Food and Drug Administration approved the 600 mg once-daily dosage because doses higher than 600 mg/day were considered to provide no additional benefits and were associated with higher rates of adverse events, such as somnolence and dizziness. Nonetheless, the results of clinical trials and post hoc meta-analyses have indicated that the 1,200 mg once-daily dosage was the most validated gabapentin enacarbil treatment for not only subjective RLS symptoms but also severe sleep disturbance associated with RLS. A Japanese dose-finding study showed that 900 mg/day, the intermediate dose between 600 and 1,200 mg, failed to show a significant improvement in IRLS total score, probably because many of the patients who discontinued treatment did so early, suggesting that a half-landing dose may cause more adverse effects than favorable ones in some RLS patients early in the treatment. Gabapentin enacarbil may have two distinct therapeutic doses for the treatment of RLS: 600 mg/day or lower doses for the treatment of subjective RLS symptoms and 1,200 mg/day or higher doses for the treatment of both subjective RLS symptoms and associated problems such as severe sleep disturbances.
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Affiliation(s)
- Akito Kume
- KUME Clinic, Nagoya, Japan ; Nagoya Clinical Neuropharmacology Laboratory, Nagoya, Japan
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28
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Giannaki CD, Hadjigeorgiou GM, Karatzaferi C, Pantzaris MC, Stefanidis I, Sakkas GK. Epidemiology, impact, and treatment options of restless legs syndrome in end-stage renal disease patients: an evidence-based review. Kidney Int. 2014;85:1275-1282. [PMID: 24107848 DOI: 10.1038/ki.2013.394] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/30/2013] [Accepted: 08/15/2013] [Indexed: 12/17/2022]
Abstract
Restless legs syndrome (RLS) (or Willis-Ekbom disease) is a neurological disorder with high prevalence among the end-stage renal disease population. This is one of the most predominant types of secondary RLS, and it is called uremic RLS. Despite the fact that uremic RLS has been less studied compared to idiopathic RLS, recent studies now shed light in many aspects of the syndrome including clinical characteristics, impact, epidemiology, and treatment options. The current review discusses the above topics with special emphasis given on the management of uremic RLS, including the management of symptoms that often appear during a hemodialysis session. Uremic RLS symptoms may be ameliorated by using pharmacological and nonpharmacological treatments. Evidence so far shows that both approaches may be effective in terms of reducing the RLS symptom's severity; nevertheless, more research is needed on the efficiency of treatments for uremic RLS.
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29
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Brown MA, Crail SM, Masterson R, Foote C, Robins J, Katz I, Josland E, Brennan F, Stallworthy EJ, Siva B, Miller C, Urban AK, Sajiv C, Glavish RN, May S, Langham R, Walker R, Fassett RG, Morton RL, Stewart C, Phipps L, Healy H, Berquier I. ANZSN Renal Supportive Care Guidelines 2013. Nephrology (Carlton) 2013; 18:401-454. [DOI: 10.1111/nep.12065] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2013] [Indexed: 12/16/2022]
Affiliation(s)
- Mark A Brown
- Departments of Renal Medicine and Medicine; St George Hospital and University of NSW; Sydney New South Wales Australia
| | - Susan M Crail
- Central and North Adelaide Renal and Transplantation Service; Adelaide South Australia Australia
- Central and North Adelaide Renal and Transplant Services; Adelaide South Australia Australia
| | - Rosemary Masterson
- Department of Nephrology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Celine Foote
- The George Institute for Global Health; Sydney New South Wales Australia
| | - Jennifer Robins
- Departments of Renal Medicine and Medicine; St George Hospital and University of NSW; Sydney New South Wales Australia
| | - Ivor Katz
- Departments of Renal Medicine and Medicine; St George Hospital and University of NSW; Sydney New South Wales Australia
| | | | - Frank Brennan
- Departments of Renal Medicine and Palliative Medicine; St George Hospital; Kogarah New South Wales Australia
- Deparments of Renal Medicine and Palliative Medicine; St George Hospital; Kogarah New South Wales Australia
| | | | - Brian Siva
- Fremantle Hospital; Fremantle Western Australia Australia
| | - Cathy Miller
- Palliative Care Service; Department of General Medicine; North Shore and Waitakere Hospitals; Waitemata District Health Board; Auckland New Zealand
| | - A Katalin Urban
- Concord Repatriation Hospital; Concord; New South Wales Australia
| | - Cherian Sajiv
- Alice Springs Hospital; Central Australian Renal Services; Alice Springs Northern Territory Australia
| | - R Naida Glavish
- He Kamaka Oranga - Department of Maori Health; Auckland District Health Board; Auckland New Zealand
| | - Steven May
- Tamworth Base Hospital; Tamworth New South Wales Australia
| | | | - Robert Walker
- Department of Medicine; Dunedin School of Medicine; University of Otago; Dunedin New Zealand
| | - Robert G Fassett
- Royal Brisbane and Women's Hospital; Herston Queensland Australia
| | - Rachael L Morton
- School of Public Health; University of Sydney; Sydney New South Wales Australia
| | - Cameron Stewart
- Centre for Health Governance, Law & Ethics; Sydney Law School; University of Sydney; Sydney
| | - Lisa Phipps
- Orange Base Hospital; Orange New South Wales Australia
| | - Helen Healy
- Deparment of Renal Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Ilse Berquier
- Central and North Adelaide Renal and Transplant Services; Adelaide South Australia Australia
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Abstract
Restless legs syndrome (RLS) is a common sensory motor neurological disorder that is characterised by an irresistible urge to move the legs that significantly affects the quality of life of the patient. Prevalence in the general population is 5-25% and it is twice as prevalent in women as in men. RLS is the most common movement disorder in pregnancy with a fourfold increased risk of developing this disorder later in life. The pathophysiology of RLS is centred on dopaminergic dysfunction, reduced central nervous system iron, genetic linkages, or alteration in neurotransmitters such as hypocretins, endorphins levels and immune dysfunction and inflammatory mechanisms. With the emergence of new evidence, there are changes to the previous treatment recommendations for RLS. There is sufficient evidence to conclude that dopamine agonists such as rotigotine transdermal patch, pramipexole, ropinirole, gabapentin enacarbil, pregabalin and gabapentin are effective in the short-term treatment of RLS and rotigotine, followed by gabapentin enacarbil, ropinirole, pramipexole and gabapentin for long-term treatment. Based on expert consensus, the recommendation for daily RLS is dopamine agonists or gabapentin or low-potency opioids. Levodopa is less preferred for treating daily RLS due to its high risk of augmentation. For intermittent RLS, it is levodopa or dopamine agonists or low-potency opioids or benzodiazepines. For refractory RLS, the choice is to change to gabapentin or a different dopamine agonist, addition of a second agent like gabapentin or benzodiazepine to the existing drug or changing to a high-potency opioid or tramadol. Medications with safety record in pregnancy include opioids and antiepileptics such as carbamazepine and gabapentin. There are concerns that patients with RLS are at risk for metabolic deregulation, autonomic dysfunction and cardiovascular morbidity. However, a recent study concluded that RLS is not associated with increased risk of cardiovascular complications.
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Affiliation(s)
- Kavitha Nagandla
- Department of Obstetrics and Gynecology, Melaka Manipal Medical College, Jalan Batu Hampar, Bukit Baru, Melaka, Malaysia.
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Lin CH, Wu VC, Li WY, Sy HN, Wu SL, Chang CC, Chiu PF, Lion HH, Lin CY, Chang HW, Lin SY, Wu KD, Chen YM, Wu RM. Restless legs syndrome in end-stage renal disease: a multicenter study in Taiwan. Eur J Neurol 2013; 20:1025-31. [DOI: 10.1111/ene.12095] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 12/11/2012] [Indexed: 01/22/2023]
Affiliation(s)
- C.-H. Lin
- Department of Neurology; National Taiwan University Hospital, College of Medicine, National Taiwan University; Taipei Taiwan
| | - V.-C. Wu
- Department of Internal Medicine; National Taiwan University Hospital, College of Medicine, National Taiwan University; Taipei Taiwan
| | - W.-Y. Li
- Department of Internal Medicine; National Taiwan University Hospital Yun-Lin Branch; Douliou Taiwan
| | - H.-N. Sy
- Department of Neurology; Changhua Christian Hospital; Changhua Taiwan
| | - S.-L. Wu
- Department of Neurology; Changhua Christian Hospital; Changhua Taiwan
| | - C.-C. Chang
- Department of Internal Medicine; Changhua Christian Hospital; Changhua Taiwan
| | - P.-F. Chiu
- Department of Internal Medicine; Changhua Christian Hospital; Changhua Taiwan
| | - H.-H. Lion
- Department of Internal Medicine; Hsin Jen Hospital; Taipei Taiwan
| | - C.-Y. Lin
- Department of Internal Medicine; En Chu Kong Hospital; Taipei Taiwan
| | | | - S.-Y. Lin
- Department of Internal Medicine; National Taiwan University Hospital Bei-Hu Branch; Taipei Taiwan
| | - K.-D. Wu
- Department of Internal Medicine; National Taiwan University Hospital, College of Medicine, National Taiwan University; Taipei Taiwan
| | - Y.-M. Chen
- Department of Internal Medicine; National Taiwan University Hospital, College of Medicine, National Taiwan University; Taipei Taiwan
| | - R.-M. Wu
- Department of Neurology; National Taiwan University Hospital, College of Medicine, National Taiwan University; Taipei Taiwan
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Korkmaz S, Tokgoz B, Ismailogullari S, Kocyigit I, Kocyigit M, Aksu OB, Aksu M. Prevalence of Restless Legs Syndrome in Patients Treated with Peritoneal Dialysis: Clinical and Biochemical Characteristics among Patients with and without Restless Legs Syndrome. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojneph.2013.31008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kapoor S. Effective treatment of restless legs syndrome in patients on haemodialysis. Nephrology (Carlton) 2012; 18:78. [PMID: 23252808 DOI: 10.1111/nep.12001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Restless legs syndrome (RLS) is a common neurological disorder of unknown etiology that is managed by therapy directed at relieving its symptoms. Treatment of patients with milder symptoms that occur intermittently may be treated with nonpharmacological therapy but when not successful, drug therapy should be chosen based on the timing of the symptoms and the needs of the patient. Patients with moderate to severe RLS typically require daily medication to control their symptoms. Although the dopamine agonists, ropinirole and pramipexole have been the drugs of choice for patients with moderate to severe RLS, drug emergent problems like augmentation may limit their use for long term therapy. Keeping the dopamine agonist dose as low as possible, using longer acting dopamine agonists such as the rotigotine patch and maintaining a high serum ferritin level may help prevent the development of augmentation. The α2δ anticonvulsants may now also be considered as drugs of choice for moderate to severe RLS patients. Opioids should be considered for RLS patients, especially for those who have failed other therapies since they are very effective for severe cases. When monitored appropriately, they can be very safe and durable for long term therapy. They should also be strongly considered for treating patients with augmentation as they are very effective for relieving the worsening symptoms that occur when decreasing or eliminating dopamine agonists.
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Abstract
Sleep disorders encompass a wide spectrum of diseases with significant individual health consequences and high economic costs to society. To facilitate the diagnosis and treatment of sleep disorders, this review provides a framework using the International Classification of Sleep Disorders, Primary and secondary insomnia are differentiated, and pharmacological and nonpharmacological treatments are discussed. Common circadian rhythm disorders are described in conjunction with interventions, including chronotherapy and light therapy. The diagnosis and treatment of restless legs syndrome/periodic limb movement disorder is addressed. Attention is focused on obstructive sleep apnea and upper airway resistance syndrome, and their treatment. The constellation of symptoms and findings in narcolepsy are reviewed together with diagnostic testing and therapy, Parasomnias, including sleep terrors, somnambulism, and rapid eye movement (REM) behavior sleep disorders are described, together with associated laboratory testing results and treatment.
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Affiliation(s)
- Vivien C Abad
- Stanford University Sleep Disorders Clinic and Research Center, Stanford University, School of Medicine, Stanford, Calif, USA
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Kakimoto S, Ozawa T, Igarashi K, Tokuno T, Kaku S, Seki N. [Pharmacological and clinical profile of gabapentin enacarbil: a novel drug for the treatment of restless legs syndrome]. Nihon Yakurigaku Zasshi 2012; 140:85-92. [PMID: 22878573 DOI: 10.1254/fpj.140.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Aurora RN, Kristo DA, Bista SR, Rowley JA, Zak RS, Casey KR, Lamm CI, Tracy SL, Rosenberg RS. The treatment of restless legs syndrome and periodic limb movement disorder in adults--an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses: an American Academy of Sleep Medicine Clinical Practice Guideline. Sleep 2012; 35:1039-62. [PMID: 22851801 PMCID: PMC3397811 DOI: 10.5665/sleep.1988] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
A systematic literature review and meta-analyses (where appropriate) were performed to update the previous AASM practice parameters on the treatments, both dopaminergic and other, of RLS and PLMD. A considerable amount of literature has been published since these previous reviews were performed, necessitating an update of the corresponding practice parameters. Therapies with a STANDARD level of recommendation include pramipexole and ropinirole. Therapies with a GUIDELINE level of recommendation include levodopa with dopa decarboxylase inhibitor, opioids, gabapentin enacarbil, and cabergoline (which has additional caveats for use). Therapies with an OPTION level of recommendation include carbamazepine, gabapentin, pregabalin, clonidine, and for patients with low ferritin levels, iron supplementation. The committee recommends a STANDARD AGAINST the use of pergolide because of the risks of heart valve damage. Therapies for RLS secondary to ESRD, neuropathy, and superficial venous insufficiency are discussed. Lastly, therapies for PLMD are reviewed. However, it should be mentioned that because PLMD therapy typically mimics RLS therapy, the primary focus of this review is therapy for idiopathic RLS.
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Affiliation(s)
- R Nisha Aurora
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Inoue Y, Uchimura N, Kuroda K, Hirata K, Hattori N. Long-term efficacy and safety of gabapentin enacarbil in Japanese restless legs syndrome patients. Prog Neuropsychopharmacol Biol Psychiatry 2012; 36:251-7. [PMID: 22036917 DOI: 10.1016/j.pnpbp.2011.10.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 09/28/2011] [Accepted: 10/12/2011] [Indexed: 11/15/2022]
Abstract
Several short- and long-term studies conducted in Europe/North America have demonstrated good efficacy and tolerability of 600-1800 mg gabapentin enacarbil (GEn). However, no studies have evaluated the efficacy of long-term treatment with GEn in Asian patients. Therefore, the objective of this study was to evaluate the efficacy and safety of long-term treatment with GEn in Japanese patients with restless legs syndrome (RLS) in a multicenter open-label study. RLS patients aged 20-80 years were allocated to receive oral GEn 1200 mg/day for a treatment period of 52 weeks. International Restless Legs Syndrome Scale (IRLS) score, investigator- and patient-rated Clinical Global Impression (CGI) scores, Pittsburgh Sleep Quality Index (PSQI) total scores and subscores, and short form (SF)-36 subscores were assessed, and adverse events (AEs) were monitored. In 181 patients (mean age, 54.9±12.2 years; BMI, 23.0±2.6 kg/m²) IRLS score decreased from 24.4±0.4 at baseline to 6.3±0.6 at week 52, with a reduction of -18.0±0.6. The IRLS responder rate was 80.3% at week 52. ICGI and PCGI responder rates were 87.1% and 87.1%, respectively. PSQI and SF-36 also showed significant improvements. AEs were reported in 96.2% of patients but remained mild-to-moderate in nearly all the cases. Serious AEs occurred in 1.6%. Dizziness and somnolence were noted in 46.2% and 41.2% of patients, respectively, and mostly occurred during the first 4 weeks. No episodes of augmentation were reported. In conclusion, long-term treatment with GEn improved RLS symptoms as well as investigator- and patient-reported outcomes in Japanese patients with moderate-to-severe RLS, with an acceptable safety profile. Randomized, double-blind, placebo/active-controlled trials are desirable to confirm these preliminary results.
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Affiliation(s)
- Yuichi Inoue
- Japan Somnology Center, Neuropsychiatric Research Institute, 1-24-10 Yoyogi, Shibuya-ku, Tokyo 151-0053, Japan.
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Abstract
Restless legs syndrome (RLS) is a common condition that is frequently unrecognized, misdiagnosed and poorly managed. It is characterized by uncomfortable sensations deep in the legs developing at rest that compel the person to move; symptoms are worst at night and sleep disturbance is common. RLS occurs in 7%-11% of the population in Western countries, and many such people experience troublesome symptoms. Primary RLS is familial in up to two thirds of patients. RLS may also be secondary to a number of conditions including iron deficiency, pregnancy and end-stage renal failure and, perhaps, neuropathy. Secondary RLS is most common in those presenting for the first time in later life. The pathogenesis of RLS probably involves the interplay of systemic or brain iron deficiency and impaired dopaminergic neurotransmission in the subcortex of the brain. RLS is very responsive to dopaminergic therapies. Rebound of RLS symptoms during the early morning and development of severe symptoms earlier in the day (augmentation) are problematic in those treated for a prolonged period with levodopa. Consequently, dopamine agonists have become first line treatment. Anti-convulsant medications and opioids are helpful in some patients. Correction of underlying problem wherever possible is important in the management of secondary RLS.
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Affiliation(s)
- Paul E Cotter
- Department of Geriatric Medicine, Galway University Hospitals Galway, Ireland
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Affiliation(s)
- Deirdre A Conroy
- University of Michigan Addiction Resarch Center, Ann Arbor, MI 48109-2700, USA
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Earley CJ, Silber MH. Restless legs syndrome: Understanding its consequences and the need for better treatment. Sleep Med 2010; 11:807-15. [DOI: 10.1016/j.sleep.2010.07.007] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 07/26/2010] [Accepted: 07/29/2010] [Indexed: 11/21/2022]
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de Oliveira MM, Conti CF, Valbuza JS, de Carvalho LBC, do Prado GF. The pharmacological treatment for uremic restless legs syndrome: Evidence-based review: Treatment for Uremic Restless Legs Syndrome. Mov Disord 2010; 25:1335-42. [DOI: 10.1002/mds.22955] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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48
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Abstract
Restless legs syndrome (RLS) is a sleep-related movement disorder commonly involving an unpleasant urge to move the limbs, typically the legs. Dopaminergic agents represent the first-line therapy for RLS; however, long-term use of such drugs results in worsening symptoms due to "augmentation" or other adverse events. Gabapentin, an analog of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), is an anticonvulsant/analgesic agent. Gabapentin is only mildly effective in relieving RLS symptoms, perhaps a result of its poor absorption from the gastrointestinal (GI) tract. Gabapentin enacarbil is a prodrug of gabapentin specifically designed to enhance absorption via the GI tract, and hence provide improved circulating levels of gabapentin on metabolism. Clinical trials to date have demonstrated favorable safety and (compared to traditional gabapentin) improved pharmacokinetics and efficacy in treating RLS symptoms. Thus, gabapentin enacarbil may prove to be a useful drug in treating RLS. An application of gabapentin enacarbil for treatment of RLS is currently pending with FDA for approval.
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Walters AS, Ondo WG, Kushida CA, Becker PM, Ellenbogen AL, Canafax DM, Barrett RW; XP045 Study Group. Gabapentin enacarbil in restless legs syndrome: a phase 2b, 2-week, randomized, double-blind, placebo-controlled trial. Clin Neuropharmacol 2009; 32:311-20. [PMID: 19667976 DOI: 10.1097/WNF.0b013e3181b3ab16] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Assess the efficacy and tolerability of gabapentin enacarbil (GEn), a transported prodrug of gabapentin with improved gabapentin exposure, in adults with moderate-to-severe primary restless legs syndrome. METHODS This 14-day, double-blind, randomized, controlled trial of GEn at 1200 or 600 mg or placebo taken once daily, evaluated the mean change from baseline International Restless Legs Scale (IRLS) total score at end of treatment (day 14:primary comparison, GEn at 1200 mg vs placebo). Secondary end points included Clinical Global Impression-Improvement scale outcomes at day 14. RESULTS Ninety-five subjects were randomized (GEn: 1200 mg, n = 33 and 600 mg, n = 29; placebo, n = 33); 2 subjects (GEn at 1200 mg) withdrew because of adverse events. At day 14,the mean (SD) change from baseline IRLS total score was significantly greater with GEn at 1200 mg (-16.1 [7.93]) compared with placebo (-8.9 [7.72]; adjusted mean treatment difference, -7.2; P < 0.0001). Investigator-rated Clinical Global Impression-Improvement scale responses also significantly favored GEn at 1200 mg compared with placebo (P G 0.0001).The mean (SD) change from baseline IRLS total score with GEn at 600 mg at day 14 was -9.1 (5.95), similar to placebo. The most commonly reported treatment-emergent adverse events were somnolence (GEn: 1200 mg, 36% and 600 mg, 14%; placebo,15%) and dizziness (GEn: 1200 mg, 18% and 600 mg, 14%; placebo, 3%), most of which were rated mild or moderate in intensity. CONCLUSIONS Gabapentin enacarbil at 1200 mg significantly improved restless legs syndrome symptoms compared with placebo. Efficacy outcomes for GEn at 600 mg were similar to placebo. Both GEn doses were generally well tolerated.
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Saletu M, Anderer P, Saletu-Zyhlarz GM, Parapatics S, Gruber G, Nia S, Saletu B. Comparative placebo-controlled polysomnographic and psychometric studies on the acute effects of gabapentin versus ropinirole in restless legs syndrome. J Neural Transm (Vienna) 2010; 117:463-73. [DOI: 10.1007/s00702-009-0361-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 12/10/2009] [Indexed: 01/13/2023]
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