A Practical Guide to the Long-term Management of Restless Legs Syndrome Experts detail their strategies for RLS patients, including non-pharmacological and pharmacological treatments, as well as how to prevent and manage augmentation. By Daniel Lee, MD, FAAN, FAASM, Angela McClees, PA-C, and Tiffany Lee, MD R Daniel Lee, MD, FAAN, FAASM Angela McClees, PA-C estless legs syndrome (RLS) or Willis- Ekbom disease (WED) is one of the most common chronic sensorimotor neurologic conditions that any clinician will ever encounter. RLS occurs in 5% to 10% of the adult population in the United States and 2% to 3% are considered to be moderate to severe. Unfortunately, only a third of them have been diagnosed, according to the National Sleep Foundation. A recent study by John W. Winkelman, MD, PhD, and his Harvard colleagues reported a strong association between RLS and cardiovascular risks, such as hypertension and heart disease. 1 He found that the higher the frequency and severity of RLS symptoms, the stronger the association. Additionally, RLS patients often complained about poor quality of life comparable to other chronic disabling medical conditions such as diabetes and arthritis. Due to the important long-term consequences of RLS and the availability of current treatment options of proven efficacy and safety, its early iden- tification and guidance for long-term treatment is highly relevant. Long-term treatment for RLS consists of non- pharmacological treatments and pharmacological treatments. Non-pharmacological Treatments Tiffany Lee, MD 16 • sleepreviewmag.com SR_16_17_RLSmanagement.indd 16 Non-pharmacological treatments include: 1. Removal of potential aggravators such as alcohol, caffeine, and nicotine, as well as sleep deprivation. 2. Consider discontinuing medications that can worsen RLS such as selective serotonin reup- take inhibitors (eg, paroxetine, fluoxetine, ser- traline), tricyclics (eg, amitriptyline, nortrip- tyline), dopamine antagonists (eg, clozapine, risperidone), and antihistamines. 3. Lifestyle changes, such as improving sleep hygiene by incorporating a regular sleep-wake schedule, a warm bath at bedtime, and mod- erate regular exercise; practicing mental alert- ness techniques and thermal biofeedback; and considering leg massage and acupuncture. 4. Mechanical device Relaxis has been approved by the Food and Drug Administration (FDA) and is designed to provide relief of RLS. But two clinical studies performed by Sensory NeuroStimulation found that Relaxis may cause leg cramping, soreness, pain, and motion sickness (in the studies, these resolved when affected participants stopped using the device). Pharmacologic TreatmentS Dopaminergic medications (DA) have been widely used over the last decade for the pharma- cological treatment of RLS. Currently, three dopa- minergic drugs—ropinirole, pramipexole, and rotigotine—and one non-dopaminergic drug— gabapentin enacarbil—are approved by the FDA for the treatment of RLS. Augmentation Overview However, long-term use of DA can worsen overall disease severity through a process called augmentation, but this has not been reported with gabapentin enacarbil. When RLS patients who had been stable on DA medications for 6 months then begin to experience a backSLIDE (see mnemonic below), one needs to consider augmentation as the cause. I summarize the diagnostic criteria of aug- mentation with the mnemonic, “SLIDE.” • S: Spread to other extremities • L: Latency of symptoms is shortened at rest • I: Intensity of symptoms is greater than before treatment • D: Duration of efficacy of DA is shortened • E: Early onset of symptom by 2 to 4 hours Because of the widespread use of DA, new cases of augmentation are increasing at an alarming rate of 8% per year. Our sleep center is facing the same MARCH 2016 2/25/16 12:28 PM