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

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.

Brazilian consensus on guidelines for diagnosis and treatment for restless legs syndrome

“…The tolerability of levodopa is greater than that of cabergoline, but evidence to the long term treatment is limited 3 . In addition, levodopa is at greater risk of augmentation than the dopamine agonists, pramipexole and cabergolina 51 .…”

“…In a retrospective study of 29 patients using methadone after failed treatment with dopaminergic agents, 63% of patients were still on methadone after 23 ± 12 months of treatment, all reporting a reduction of at least 75% of symptoms without augmentation. All these studies, coupled with clinical experience suggests that opioids are particularly useful for patients with refractory forms of RLS and/or development of augmentation when treated with other agents, or for use as needed in patients with intermitent symptoms 51,81 . Pharmacological efficacy of opioids seems to be specifically related to Mu type, as opposed to Kappa type opioid receptor agonism, which has practical implications for drug choice 79 .…”

“…Therefore, patients should be clinically monitored for these symptoms. In general, however, these drugs are well tolerated 51 . There is a case report of augmentation with long term use of tramadol 82 .…”

“…The use of levodopa can be more advantageous than other therapies for patients with intermittent symptoms of RLS not requiring daily treatment (using "as needed") 51 . The tolerability of levodopa is greater than that of cabergoline, but evidence to the long term treatment is limited 3 .…”

“…Along with pramipexole, ropinirole is recommended for the treatment of RLS by American and European consensus with the same degree of recommendation (A) and level of evidence (1A). This recommendation is endorsed by at least seven randomized, placebo controlled double blind trials 51,57 .…”