4.9.1 Dopaminergic drugs used in restless leg syndrome |
Diagnosis of restless legs syndrome (RLS) can be made if all of the following four criteria are met: |
|
> a need to move the legs, usually accompanied or caused by uncomfortable, unpleasant sensations in the legs, |
> symptoms are exclusively present or worsen during periods of inactivity/rest, |
> symptoms are partially or totally relieved by movement such as walking or stretching at least as long as the activity |
continues. > symptoms are generally worse or exclusively occur in the evening or during the night | |
|
Guidelines on the management of Restless Leg Syndrome in primary care can be accessed here |
|
Once a diagnosis has been made, the patients severity of symptoms should be scored using the International Restless Leg |
Syndrome (IRLS) rating scale. See appendix II. |
|
Other secondary cases should be referred to a specialist for diagnosis (e.g. renal failure). Dopamine agonists are not licensed for |
the management of secondary RLS, only idiopathic RLS. Try to avoid drugs that can exacerbate symptoms (CNS stimulants, |
diuretics, tricyclic antidepressants, calcium antagonists, phenytoin). |
|
Patients with paroxsysmal RLS should be offered advice on sleep hygiene and other non-pharmacological measures which will |
reduce symptoms in some patients. Should these measures fail, pramipexole may be offered on a ‘when required’ basis in line |
with the recommendations below. |
|
Patients with moderate to severe RLS (as rated on the IRLS scale, 15 to 40 points) should also be offered sleep hygiene advice and |
non-pharmacological measures. Patients may consequently be offered treatment with pramipexole, which may be initiated by any |
prescriber for the treatment of restless leg syndrome (RLS) in line with the product licence and the following recommendations; |
|
> to be initiated in patients with primary (idiopathic) RLS only |
> serum ferritin should be checked to exclude iron deficiency as a cause. If ferritin <20mcg/L then oral iron |
supplementation should be offered initially |
|
Pramipexole – 1st Line Choice |
> treatment should be initiated at pramipexole 125micrograms/day. Many patients respond to this dose within one week. |
Dose increases to pramipexole 125micrograms/day and pramipexole 500micrograms/day should be undertaken in one |
week intervals only where necessary. Maximum dose of pramipexole 750micrograms/day should rarely be required. |
The dose should be taken 2-3 hours before bedtime. [Doses stated relate to pramipexole dihydrochloride] |
> Patients should be counselled that treatment with a dopamine agonist can in some patients exacerbate symptoms, or cause them to appear earlier in the day (augmentation). Some patients see a rebound in symptoms on cessation of |
treatment. Relapse rates with long term treatment are also unknown at this stage. Dopamine agonists can also cause |
sudden hypersomnia - patients should also be warned of this overwhelming sensation of sleepiness occurring with little |
or no warning, and the need to exercise caution when driving or operating machinery. They are also rarely associated |
with pathological gambling. |
> Treatment should be reviewed at 3 months and stopped if little or no benefit seen. Patients should be referred where |
there is neurological comorbidity (if this requires assessment or seriously impedes diagnosis), failure of response to two |
dopamine agonists, or augmentation occurs. |
|
GREEN Generic Pramipexole dihydrochloride tabelts 125 micrograms, 250 micrograms |
|
Ropinirole – 2nd Line Choice |
Ropinirole may only be initiated for the treatment of RLS where the use of pramipexole is inappropriate, not tolerated or |
ineffective. Efficacy data for the licence for ropinirole comes from those patients with an IRLS score of 24 or above (rather than 15 |
or above with pramipexole); dose titration is slower than with pramipexole and costs more at the average dose. Starter packs are |
available for initial dose titration up to 0.5mg/day. |
|
GREEN Ropinirole |
tablets 0.25mg, 0.5mg, 2mg & ‘starter pack’ |
|
Back to Main Chapter |