Restless Leg Syndrome

1. Restless Leg Syndrome • “The most common disorder you have never heard of.”

2. What are Restless legs? • Neurological movement disorder • Irresistible urge to move legs when at rest • Difficulty sleeping • Involuntary periodic leg movements • Uncomfortable sensation in limbs subjective & difficult to describe • Symptoms eased by movement

3. Why should we know about it? • Excess 5 million in UK are sufferers (MEMO 2000) • Estimated prevalence 2-15% • Sufferers will present to primary care • Important physical cause of sleep disturbance • Clinical diagnosis which can be made in primary care

4. Why should we know about it? • Unrecognised & under-diagnosed • Incorrectly labeled as stress / anxiety • Managed poorly

5. Wide spectrum • Affects any age group • More common in middle age + women • Mild • Minimal distress • Severe • Episodes occur >2 per week • Can be disabling

6. Why is it important? • Large impact on quality of life: (REST Study) • Poor sleep • Inability to get comfortable / relax • Poor concentration / fatigue • Pain • Depression • Problems in day to day functioning / employment • Implications for partner

7. Common descriptive terms used by patients

8. How do we diagnosis RLS? • International Restless Legs Syndrome Study Group - 2003

9. Supporting Features • Positive FHx (50-92%) • Involuntary limb movements (80%) • Sleep disturbance

10. What investigations should we do? • Exclude secondary cause. • Vascular dx / Neuropathy / nocturnal cramp / anxiety • Examination • Neuro / vascular • Bloods • FBC, ferritin, B12, Folate, U&E, Glucose, TFT

11. Aetiology • Primary • No underlying cause found. • Positive FHx >50% • Earlier onset / slower progression • Secondary • Fe deficiency • Pregnancy • End stage renal disease • Peripheral neuropathy / DM / RA / Fibromyalgia • Later onset / more severe

12. Pathophysiology • Genetic • Susceptibility loci identified on 3 chromosomes • Positive FHx >50% • Neurochemical • Dopaminergic dysfunction - universal response to dopaminergic agents • Ferritin level - inverse relation between severity and serum ferritin

13. What are the treatment options? • Non Pharmacological • Preventative measures • Symptomatic control • Pharmacological • PRN treatment - mild / intermittent • Maintenance treatment - moderate / severe • Majority of treatments used ‘off license’

14. Non pharmacological treatment • Preventative • Avoid caffeine / alcohol / nicotine • Avoid medication which may aggravate • SSRI / antihistamine / antiemetic / CaChannel blockers • Keep active into evening • Good sleep hygiene • Symptom control • Mental alerting activities • Walking / stretching • Massage • Hot / cold bath • Relaxation / biofeedback

15. Pharmacological options

16. Pharmacological options

17. Rx Flow chart - RLS:UK

18. Mirapexin (pramipexole) • First drug treatment / ONLY treatment licensed in EU for RLS • For use in moderate / severe disease • Quick onset of symptom relief (<1/52) • Start low dose 125mcg od • Titrate up (max 750mcg od)

19. What should we be doing? • Have raised awareness about diagnosis • Exclude / treat secondary causes • Symptoms generally mild + reassurance & non-pharmacological measures suffice • In moderate / severe cases consider onward referral

20. Useful Info • Resources • www.ekbom.org.uk • www.restlesslegs.org.uk • www.restlesslegs.com • Review • DTB Nov 2003 • Bandolier 118