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Restless legs syndrome

Definition
RLS is a neurologic disorder that is characterized by a strong urge to move one's legs, which is exacerbated during rest or inactivity.
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Pathophysiology
RLS may be idiopathic, or may occur in the context of neurological disorders (such as spinal cord injury or stroke), obstructive sleep apnea, iron deficiency, pregnancy, chronic renal failure, and use of certain drugs (antidepressants, neuroleptics, cumulative dopaminergic agonists).
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Epidemiology
The prevalence of RLS in the US is estimated at 10%.
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Disease course
RLS results from alterations in the function of dopaminergic neurons within the CNS, which promote spinal hyperexcitability and result in spontaneous sensory and motor disturbances.
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Prognosis and risk of recurrence
Loss of efficacy and augmentation are two main types of treatment failures occurring in patients receiving long-term treatment for RLS. Augmentation refers to a medication-induced worsening of the symptoms. The augmentation rate for pramipexole, ropinirole, and rotigotine is 65% at 10 years, 24% at 5 years, and 13% at 5 years, respectively.
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Key sources
The following summarized guidelines for the management of restless legs syndrome are prepared by our editorial team based on guidelines from the American Academy of Neurology (AAN 2016).
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Guidelines

1.Medical management

Indications for treatment: consider initiating pharmacotherapy for symptomatic relief in patients with moderate-to-severe primary RLS.
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  • Dopaminergic agents

  • Non-dopaminergic agents

  • Management of treatment failure

  • Management of hypoferritinemia

  • Management of periodic limb movements of sleep

  • Management of sleep disturbance

  • Management of psychiatric symptoms

  • Agents with no evidence for benefit

2.Nonpharmacologic interventions

Device therapy: consider offering pneumatic compression before usual symptom onset
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and near-infrared spectroscopy or repetitive transcranial magnetic stimulation in patients wishing nonpharmacological treatment approaches.
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  • Acupuncture

3.Specific circumstances

Patients with end-stage renal disease
Consider offering vitamin C and E supplementation, alone or in combination, as first-line therapy in patients with secondary RLS associated with ESRD on hemodialysis.
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Consider offering ropinirole, levodopa, or exercise as treatment options.
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Insufficient evidence to recommend for or against the use of gabapentin or IV iron dextran in patients with secondary RLS associated with ESRD on hemodialysis. Insufficient evidence to recommend for or against the preferential use of gabapentin or levodopa over other agents in these patients.
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