The American Academy of Sleep Medicine [AASM] has released a new clinical practice guideline seen in the Journal of Clinical Sleep Medicine regarding the treatment of restless leg syndrome [RLS], a neurological disorder which triggers a strong urge to constantly move the legs.
The updated guideline calls for new forms of treatment over some traditional forms due to worsening side effects seen in patients who have used these treatments long-term.
In the latest edition of Sound Health, psychiatrist Rachel Immen, who is also credentialed as a sleep medicine physician, of Carle BroMenn Medical Center in Normal, explained who RLS affects and why dopamine, a pleasure hormone in the brain, could play a key role in its cause.
“It impacts a wide range of individuals,” Immen said. “It can start in early childhood and range throughout adulthood.”
“The cause of RLS is unknown, however the theory is that is has to do with dopamine levels and how dopamine works,” Immen continued. “One of the many roles of dopamine is to control muscle movement. It is a lack of dopamine working properly in that it cannot send the proper signals from the brain to the body.”
One of the changes put in place by the AAMS is the decreased use of dopamine agonist medications, which are meant to help increase dopamine levels, due to harmful long-term side effects which have been found in RLS patients.
“Initially, these medications were FDA approved in the 1990s and it showed a wonderful response where individuals would have less severe symptoms, improved quality of life, improved quality of sleep, and those were all great initial findings,” Immen said.
Immen explained what kinds of complications long-term use of dopamine agonist medications have led to.
“The medication can start by improving symptoms, but eventually they lead to the symptoms getting much worse than they ever were to start with,” Immen said. “The symptoms are quite specific. Sometimes it’s difficult to describe, but clearly an uncomfortable feeling that you must move your legs.”
“Sometimes people will use the word ‘pain’ and others will say it’s not quite pain,” Immen continued. “Some will say it’s a nagging, aching feeling, but in the end, they feel a very strong urge to move their legs to the point that they have to get up and move around even if it’s 2 a.m. and they haven’t slept.”
Immen said some of the newer treatments for RLS include monitoring blood iron levels, which will ensure the body has enough oxygen, use of the seizure-preventing medication gabapentin and abstaining from alcohol and caffeine.
“The role of iron has long been considered and discussed … the evidence has been a more recent additional piece of information,” Immen said.
Medications which are based on histamine, an immune response compound, and the stress hormone serotonin are also harmful for RLS patients, according to Immen.
Immen explained why switching from dopamine agonist medications to these newer forms of treatment can be extremely difficult.
“It is not an option to abruptly stop a dopamine agonist,” Immen said. “It would lead to a lot of difficulty. I’ve had people who have abruptly stopped [the use of] dopamine agonist and end up in the emergency room or hospitalized; the withdrawal symptoms are severe.”
“It can range to the point that someone becomes delirious, or they don’t have a good understanding of where they are, who they are or what’s going on or even having hallucinations that are visual or auditory,” Immen continued. “Cognitively, they start to significantly decline.”
Immen said that the implementation of the new guidelines will take time.
“I encourage people to start having this conversation,” Immen said. “Do not abruptly stop these [dopamine agonist] medications but talk to your primary care provider and work through a plan to find a good alternative treatment.”
