Introduction to Management of Restless Legs Syndrome

Published on 12/04/2015 by admin

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Chapter 29 Introduction to Management of Restless Legs Syndrome

As demonstrated by the chapters that follow, there are numerous therapies that have been tried for the restless legs syndrome (RLS), and for many of them there is some evidence of success. Although it is fairly easy to summarize—and assess—the evidence for specific treatments, a management plan has been more a matter of expert opinion. The basis for management was set out by the American Academy of Sleep Medicine (AASM) Standards and Practice Committee (SPC) in their first standards for RLS treatment in 1999.¹ That document specific elements that were standards, that is, essentially mandated (the SPC indicates that a standard is, “a generally accepted patient-care strategy which reflects a high degree of clinical certainty”), for the proper management of RLS patients:

1. Pharmacological treatment of RLS and/or PLMD should be limited to patients who meet specific diagnostic criteria (Standard). (The issues of proper diagnosis are discussed in the several chapters dealing with diagnosis and differential diagnosis.)

2. The physician who evaluates and treats patients with RLS and/or PLMD should be aware of the existence of idiopathic and secondary forms, and should be knowledgeable about risk factors and co-morbid conditions for these disorders (Standard). (These different forms of RLS, risk factors, and comorbid conditions are discussed throughout the book in numerous chapters.)

3. Individuals with RLS and/or PLMD who are being treated with medication should be followed by a physician at appropriate intervals and monitored for adverse side effects, augmentation, and tolerance (Standard). (The issues of adverse side effects, augmentation, and tolerance are discussed in the chapters on specific therapies. Augmentation is discussed extensively in the Chapter 31.)

This book should provide a solid foundation for fulfilling these management standards. This publication was historically quite important for its indication that the management of RLS was a significant medical enterprise.

The one publication presenting a somewhat comprehensive algorithm for management was produced several years ago by the Medical Advisory Board of the RLS Foundation (RLSF).² By now, some of its specific recommendations are somewhat outdated, but the general scheme remains quite valid. First, the algorithm suggests three major classes of patients—those with intermittent RLS who may need only occasional therapy, those with daily or near-daily RLS who will benefit from daily medication, and those who have become refractory to initial first-line therapy, especially those who cannot tolerate or have developed augmentation on one or more agonists. Second, the scheme indicates that nonpharmacological therapy, mainly behavioral therapy and the avoidance of provocative substances, is something that should be incorporated into the management scheme for all patients, even if pharmacological therapy is also mandated. Third, the scheme recognizes the importance of assessing iron status and treating iron deficiency if it exists. Fourth, the algorithm suggests ways to manage the various classes of patients (Table 29-1).

TABLE 29-1 The Restless Legs Syndrome Foundation Medical Advisory Board Update

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