Treatment of RLS
Managing your RLS with Medication
Some people have no choice but to take medication to manage their RLS. There are a number of medications available that may help ease your RLS. The following is an overview of some of these. You should always speak to your doctor about any questions relating to medication.
MANAGING YOUR RLS WITH MEDICATION
If raising serum ferritin above the recommended levels, and replacing trigger medications does not help, some people have no choice but to take medication to manage their RLS. The UK NICE and NHS guidelines are slightly out of date and the best, most up to date resource for the treatment of RLS is contained in the Mayo algorithm, written by the world’s top RLS experts. The Management of Restless Legs Syndrome: An Updated Algorithm - Mayo Clinic Proceedings
Carbidopa Levopdopa, low dose opioids and benzodiazepines can all be useful to treat intermittent, occasional RLS.
Carbidopa Levodopa is a dopaminergic drug and should be used with caution due to the high rate of augmentation (drug induced worsening of RLS) which occurs in up to 70% of patients taking it on a daily basis. For this reason, it should be prescribed only for intermittent use.
Opioids, such as codeine, hydrocodeine, oxycodone or tramadol can be effective at low dose in the evening to treat occasional RLS and the common side effects of nausea and constipation can be easily managed.
Benzodiazepines (diazepam, lorazepam, temazepam, clonazepam) before sleep may be useful for occasional RLS but longer lasting agents, like clonazepam, may result in more adverse effects such as unsteadiness in the night and daytime drowsiness and cognitive impairment.
CHRONIC PERSISTENT RLS
RLS that occurs on average at least twice a week will require daily treatment.
Dopamine agonists (Ropinirole, Pramipexole, rotigotine patch) are no longer first line treatment amongst experts due to the high risk of Augmentation (drug induced worsening of RLS) and Impulse Control disorders. If you are on any of these medications, you should arrange a review with your doctor to discuss augmentation and, if the drug has lost effectiveness, to discuss a slow taper and a switch to another medication in another class of drugs. Withdrawal from dopamine agonists can be very difficult and traumatic and will require careful monitoring.
Alpha 2 delta ligands should, when not contra indicated, be tried as first line treatment. Gabapentin and Pregabalin are usually administered in the evening. Gabapentin is not easily absorbed above 600mg so split doses two hours apart may be required to enhance absorption and efficiency. Magnesium supplements can affect absorption and are best taken two hours before gabapentin. Gabapentin should be started at 300mg (100mg for over 65) and increased every few days. Average dose is 1200-1800mg. Pregabalin is more easily absorbed and can be taken in one dose. starting dose is 75mg (50mg for over 65) and the average dose is 150-200mg. Gapabentin and Pregabalin can take up to 3 weeks to become fully effective and common side effects of drowsiness, dizziness, unsteadiness, oedema, weight gain usually resolve after 6 to 8 weeks. Side effects can include depression and suicidal ideation and should be monitored, especially at higher doses.
Where first line treatments have failed due to adverse effects or augmentation, low dose opioids are highly effective and do not generally lead to addiction or tolerance if patients are adequately screened and monitored. The Massachusetts General Hospital Opioid Study shows that long term, low dose opioids used in RLS do not lead to an increase in dose over long periods of time. (National RLS Opioid Registry (massgeneral.org). Opioids should not be withheld due to fear of tolerance or dependence as they can result in complete resolution of refractory RLS and improved quality of life.
in the UK, Oxycodone is licensed for RLS, but codeine, tramadol and buprenorphine can be prescribed off licence. Most general Practitioners may be reluctant to prescribe opioids without the supervision of a neurologist.
Tramadol is the only opioid that can cause augmentation and worsening of symptoms should be monitored.
Common side effects of nausea, skin itching, sweating and anxiety should be monitored and treated accordingly.
MEDICATIONS TO AVOID
A number of medications can make RLS worse. In particular, anti-nausea drugs and sedating antihistamines can block the brain’s dopamine receptors, increasing the symptoms of restless legs. Antidepressants that increase serotonin and antipsychotic medications can also aggravate the condition. Let your doctor know if your restless legs symptoms worsen after you take a new medication. A change in dosage or a change to a different medication may help. Below we have listed a number of medications which our forum users suggested made their RLS worse. Please note that this list is not exhaustive and while we have been advised that they have made RLS symptoms worse for some people, this may not be the case for you.
In particular, anti nausea drugs and sedating anti histamines can block the brains' dopamine receptors, increasing the symptoms of restless legs. Anything containing pseudoephrine or phenylephrine should be avoided.
Cold and Flu remedies and Anti-Histamines: Common culprits include: Night Nurse, Day Nurse, Nytol, Actifed, Avamys, Benadryl (Acrivastine), Chlorphenamine ( Piriton), Contac, Coricidin, Fluticasone, Rhinolast (Azelastine hydrochloride), Sinutab, Sudafed. Note that many cough syrups may contain antihistamines, especially if they are recommended for cold or flu symptoms. Always try to choose non-drowsy options.
Anti-depressants: Many people living with RLS also live with depression and consequently are prescribed anti-depression medication. RLS is also common in two conditions that often co-occur with depression: ADHD and PTSD. However some anti-depressants can actually make RLS symptoms worse. If you are prescribed anti-depressants and live with RLS, we recommend you monitor your RLS symptoms to see if your symptoms worsen after starting anti-depressant medication. If so, speak to your medical practitioner to see if you can be prescribed an alternative medication. Trazodone and Bupropion are both RLS safe alternatives.
Anti-psychotics: Most anti psychotics worsen RLS.
Selective Serotonin-Reuptake Inhibitors (SSRIs) and Serotonin and Norepineephrine Reuptake Inhibitors (SNRIs):
Citalopram (Cipramil), Duloxetine (Cymbalta), Venlafexine (Efexor), Escitalopram (Cipralex), Paroxetine (Paxil, Seroxat), Fluoxetine (Prozac), Nefazodone (Serzone, Dutonin, Nefadar), Setraline ( Zoloft, Lustral), Dapoxetine (Priligy), Fluvoxamine (Faverin), Vortioxetine (Brintellix).
Tricyclic medications: Amitriptyline (Tryptizol), Clomipramine (Anafranil, Imipramine (Tofranil), Lofepramine (Gamanil), Nortryptiline (Allegron), Amoxapine, Desipramine (Norpramin), Doxepin, Trimipramine, Imipramine, Mirtazapine ( Zispin), Protriptyline, as well as others, have been suggested as making the symptoms of RLS worse.
Antacids: Most Proton Pump Inhibitors worsen RLS. Omeprazole, Lansoprazole, Pantoprazole, Rabeprazole, Esomeprazole.
Anti Nauseates: Discuss any anti nauseates with your doctors before surgery as many, including prochlorperazine or metoclopramide) will trigger RLS during and after surgery. Safe alternatives include Odansetron ( Zofran), domperidone or granisetron hydrochloride.
COMMONLY PRESCRIBED RLS MEDICATIONS
Some of the most frequently prescribed RLS medications are listed below, accompanied by details of the recommended starting, average and maximum daily dosage, and the expected half-life of the drug (how long a drug takes to lose half its strength).
Please note that the following is an overview and does not capture every medication used to treat RLS. You may also find that the amount you are prescribed differs from the doses suggested below. These details are for information only but we hope they will help you in making informed decisions with your GP.
MEDICATIONS TABLE - see downloadable and printable pdf below