March 31st, 2016

Restless leg syndrome in the emergency department: Things I know nothing about

By Shawna Bellew, M.D.

Restless leg syndrome (RLS) is a surprisingly common and distressing condition that affects about 2-3% of the general population. Yet, this topic is one which few medical schools include in their curricula.

Therefore, I am likely not alone when I admit that I knew almost nothing about this problem when a patient presented to my small-town emergency department complaining of intractable, unbearable nocturnal “cramping” associated with the urge to move and somewhat alleviated with purposeful action.

Later, I found this description of a patient’s experience of an emergency department visit for RLS symptoms: “After waiting what seemed like hours, an emergency room doctor spoke to me. To my amazement the doctor could not pinpoint what exactly was happening to me. I couldn’t sit, nor could I stand in one place for more than a few seconds. Finally, after hours and hours they sent me home no better than I was when I first entered the hospital.1

I can vividly imagine this patient’s frustration as well as this emergency medicine physician’s predicament, as I recall my own reaction to my patient, finding my own knowledge base bereft and requiring a cursory glance of the ever-and-all-knowing Dr. Google.  I was unable to find a resource specific to emergency department management. Perhaps this deficit is because evaluation and treatment of this typically chronic, non-life-threatening condition is not best suited to emergency care- much like many other conditions we commonly see, and treat, in the ED.

  • Restless leg syndrome (RLS) is also eponymously called Willis-Ekbom disease (WED).
  • RLS most commonly occurs in older patients but can also begin in childhood. Actually, many adults with RLS recall having symptoms before the age of 10 years.
  • RLS is associated with iron deficiency, certain medications (anti-histamines, neuroleptic medications ie Reglan), kidney failure (Uremia), and pregnancy.
    • Iron is an essential co-factor in the metabolism of dopamine, the primary neurotransmitter implicated in the pathogenesis of RLS2.
  • Symptoms are typically associated with inactivity (occurring in the evening), are felt in the lower legs, and are described as a need to move, sometimes associated with abnormal sensations. Symptoms can be painless to very uncomfortable, can prevent sleep, can also affect the upper extremities (not just the legs), and can occur during the day.
  • Can be differentiated from:
    • Akathisia, which tends to be more generalized, lack paresthesia/noxious sensations, and is not relieved by voluntary movement.
    • Nocturnal leg cramps, which are characterized by tonic contractions of the muscles which are palpable and usually short in duration.
  • Treatment of RLS in the emergency department is far from ideal and ultimately therapies require a long-term relationship with a primary care or specialist provider given that medication options have potentially serious side effects, can become ineffective over time, and require up titration for efficacy. That being said, we will encounter patients on these medications and can offer these patients understanding, lifestyle modification counseling, as well as potentially offer short term medication options.
    • Patients with low ferritin levels should have iron replacement and monitored iron levels.
    • Recommended lifestyle modifications include:
      • Engaging in regular physical activity.
      • Avoidance of caffeine.
      • Avoidance of sleep deprivation.
      • Engaging in mentally or physically stimulating activities to offset symptoms (i.e. reading before bed/doing Sodoku or a similar activity).
      • Avoidance of certain medications if possible:
        • SSRI,SNRI, and tri-cyclic antidepressants
        • PPIs can interfere with iron absorption and therefore potentiate RLS
    • Pharmacologic measures include:
      • Severe, ongoing symptoms:
        • Dopamine agonists:
          • Names: Pramipexole (Mirapex), ropinirole (Requip), rotigotine
          • Notable adverse effects:
            • Impulse control disorders (ie gambling, sexuality, compulsive shopping).
            • Augmentation, meaning symptoms actually get worse (and typically begin earlier in the day) with use over time and medication loses efficacy.
            • Rebound effect with discontinuation.
        • Calcium channel alpha-2-delta ligands (reduce neurotransmitter release):
          • Names: Gabapentin (Neurontin), Pregabalin (Lyrica)
      • Intractable symptoms, breakthrough symptoms despite other therapies, or intermittent symptoms:
        • Opioids: There is some thought that RLS patients have decreased endogenous opiates that contribute to their sensory symptoms. Oxycodone may actually decrease motor RLS symptoms as well3.  Combinations of oxycodone with naloxone have also been shown to reduce symptoms4.
    • The FDA has recently approved this device as well: http://myrelaxis.com/, which has tepid efficacy in limited clinical trials that have been performed as of yet. TENS units, which can be purchased inexpensively, can also be utilized but has not been extensively studied for this indication.5

Ultimately, what I love about emergency medicine is witnessing, diagnosing, and alleviating-to the best of my ability-the full gamut of human disease. Restless leg syndrome is no exception. While I may, and probably should, not be comfortable prescribing a dopamine agonist for these conditions, I would definitely consider opiate administration in the right circumstance. Even more importantly, I now feel that I will better understand this potentially disabling and distressing syndrome, and therefore better empathize with and inform my patients.

References: 

  1. Chokroverty S. 100 Questions & Answers About Restless Legs Syndrome. 1st ed. Jones & Bartlett Learning; 2010.
  2. Wijemanne S, Jankovic J. Restless legs syndrome: clinical presentation diagnosis and treatment. Sleep Med. 2015;16(6):678-690. doi:10.1016/j.sleep.2015.03.002.
  3. Walters AS, Wagner ML, Hening WA, et al. Successful treatment of the idiopathic restless legs syndrome in a randomized double-blind trial of oxycodone versus placebo. Sleep. 1993;16(4):327-332. http://www.ncbi.nlm.nih.gov/pubmed/8341893.
  4. Trenkwalder C, Beneš H, Grote L, et al. Prolonged release oxycodone-naloxone for treatment of severe restless legs syndrome after failure of previous treatment: A double-blind, randomised, placebo-controlled trial with an open-label extension. Lancet Neurol. 2013;12(12):1141-1150. doi:10.1016/S1474-4422(13)70239-4.
  5. Mitchell UH. Medical devices for restless legs syndrome – Clinical utility of the Relaxis pad. Ther Clin Risk Manag. 2015;11:1789-1794. doi:10.2147/TCRM.S87208.

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Liked by Damian Baalmann, M.D., txmed7

COMMENT

rcsofttech
@rcsofttech

Posts: 4
Joined: Apr 06, 2016
Posted by @rcsofttech, Apr 6, 2016

thanks for the information,really helpful.
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