Restless Legs Syndrome: Who are Willis and Ekbom?

Transcription

1 Restless Legs Syndrome: Who are Willis and Ekbom? Rochelle Goldberg, MD, FAASM, FCCP Associate Professor, Sidney Kimmel Medical Center, Thomas Jefferson University Director, Sleep Medicine Services Main Line Health

2 Disclosures Speaker: Teva, UCB, Purdue Advisory Board: Welltrinsic Sleep Network Consultant: Vapotherm, Inc. National Interpretor: Novasom

3 Outline Definition Mechanisms Differential diagnosis Clinical presentation Risk factors, co-morbidities Evaluation Treatment

4 Willis-Ekbom Syndrome? KA Ekbom-setting the record straight In 1944, I described an old, almost completely ignored syndrome, which I have denoted restless legs. Its clinical features are simple and easily recognized. The syndrome is so common and causes such suffering that is should be known to every physician.

5 Willis-Ekbom Syndrome? Dr. Willis Ekbom s syndrome was graphically described in the 17 th century by that great clinical neurologist, Thomas Willis he wrote: Wherefore to some, when being a Bed they betake themselves to sleep, presently in the Arms and Leggs, Leapings and Contractions of the Tendons, and so great a Restlessness and Tossings of the Members ensue, that the diseased are not more able to sleep, than if they were in a Place of the greatest Torture.

6 Willis-Ekbom Syndrome Ekbom (continued) The symptoms [per Willis and others] were thus attributed as hysterical or neurasthenic and were accorded little interest. Interestingly, dating to 1945, there were observations of restless legs in anemia

7 Ekbom Syndrome Not to be confused with Wittmaack-Ekbom syndrome (restless legs syndrome) Condition identified as delusions of parasitosis or invisible bug infestations Patients may also have visual hallucinations, and tactile hallucinations including a crawling sensation Perched in the psychiatry literature as a rare condition

8 Restless Legs Foundation and Willis Ekbom Disease Restless Legs Foundation: non profit support network for patients affected by RLS Rationale for renaming Opportunity to clarify more varied symptom complex Better understanding of pathophysiology to clarify as a disease, not syndrome Encourage further investigation into disease mechanisms and treatment options

9 Definition: ICSD-3 Diagnostic Criteria (must meet A-C) A. Urge to move the legs, generally with an sense of discomfort/ unpleasant sensation Sx begin or worsen with rest/ inactivity Sx are partially or fully relieved with movement Occur predominantly during evening or night B. Cannot be explained by other condition C. Symptoms cause distress, sleep disturbance or daytime functional challenge

10 RLS: ICSD Qualifiers Urge to move may sometimes be without the unpleasant sensation; may sometimes involve arms or other body parts Children may use different words to describe If very severe, relief with activity may not be reported (though must be previously noted)

11 RLS Pathophysiology The case for dopamine mechanism Strong pharmacologic response to dopamine agonists Exacerbation by dopamine antagonists Iron deficiency role

12 Dopamine Synthesis: Why Iron Matters

13 RLS: Differential Diagnosis Leg cramps Positional discomfort Arthralgias, arthritis Myalgias, radiculopathy Peripheral neuropathy Leg edema Habitual foot tapping

14 Clinical Presentation Sleep disturbance is usual presenting complaint (60-90% of patients) Problem typically is difficulty falling asleep Often report disturbed sleep, daytime fatgue Sleepiness less prominent, often low Epworth score Sx of PLMD, positive family Hx and response to dopamine agonists also support diagnosis Severity score (IRLSSG)

15 RLS: The Statistics Prevalence: 5-10% (N. America, Europe) Less common in Asian populations Increases increases till age Women: Men= 2:1 Pediatric population 2-4% Equal female: male (until late teens)

16 RLS: Clinical Course Onset childhood-late adult years Slower progression with early age of onset Remission reported, though likely lifelong Mental and physical impairment (HRQoL) Correlates with severity of RLS symptoms Mortality data (limited) Increased risk in women and with CRF

17 Familial RLS Early onset (<45 years old) more common 40-92% patients report positive family history Slower progression Genetic studies indicate (complex) geneenvironmental linkage

18 Risk Factors and Associations Positive family history Female gender Pregnancy 2-3X general population Explains gender stats Chronic renal failure 11-58% May discontinue HD early Improves with transplant Alcohol, caffeine, nicotine Iron deficiency Ferritin < 50 mcg/l Medication Sedating antihistamines e.g. diphenhydramine Antidepressants Most SSRIs MAOIs NOT bupropion *** Dopamine promoting action

19 RLS: Comorbidity Increased prevalence of mood and anxiety DX Major depression, GAD, panic disorder, PTSD Treatment of RLS often improved depression Sx Association of RLS and ADHD 25% of RLS patients have ADHD Sx (peds, adults) 12-35% of ADHD patients meet RLS criteria

20 RLS: Comorbidity Other medical conditions: Narcolepsy, OSA, nocturnal eating, COPD, cardiovascular disease, stroke, DM, Migraines, MS, peripheral neuropathy, Parkinson s, Thyroid disease, rheumatoid arthritis, fibromyalgia

21 Evaluation History is key SIT and FIT (forced immobilization test) Ferritin level (measure iron stores) Sleep testing Not indicated for RLS alone May be considered if concomitent sleep fragmentation (e.g. PLMs, sleep apnea)

22 Fig. 1 Forced Immobilization Test (FIT) Sleep Medicine , DOI: ( /j.sleep ) Copyright 2013 Elsevier B.V. Terms and Conditions

23 Fig. 2 Substantia nigra findings in RLS Sleep Medicine , DOI: ( /j.sleep )

24 Treatment Avoid caffeine, nicotine, alcohol Consider medication adjustment if treated with meds that exacerbate Check ferritin level (iron stores) Supplement if ferritin <50mcg/L Aim mcg/l

25 Fig. 1 RLS Severity and Ferritin Levels Sleep Medicine , DOI: ( /j.sleep )

26 Treatment: Medications Dopamine agonists (ropinirole, pramipexole) Dopamine precursor (levodopa) Gabapentin, pregabalin Benzodiazepines/ Opiods

27 Treatment: Other OTC preparations e.g. Restful Legs No RCT for these agents Relaxis vibration pad FDA approved for RLS

28 Treatment Details Treatment is symptomatic Dosing titrated for symptoms Dose timing is key 1-3 hours before symptom onset Combined with Fe supplement-reassess Augmentation A phenomenon of dopamine agonists and L-dopa

29 Rebound and Augmentation Rebound: symptoms worsen at the end of dosing period, therefore recur either late in the night or with morning wake Augmentation: usually after long-term use Symptoms move earlier in the day Extend to other parts of the body Occurs with L-dopa and the dopamine agonists May be more likely with more severe RLS and higher medication dosing (L-dopa, not agonists?)

30 Periodic Limb Movements and Periodic PSG finding Limb Movement Disorder Periodic bursts of stereotypic movements during sleep May involve legs and arms Movement may be associated with arousal/awakening Finding periodic limb movements on a sleep study is NOT a diagnosis of the condition of periodic limb movement disorder Findings and symptoms must be correlated to make a diagnosis

31 PLMD: ICSD-3 Criteria PLMS measured on the polysomnogram Index: adults >15/hr; pediatric >5/hr Complaint of sleep disturbance/ daytime functional impairment Symptoms not explained by other condition Evaluate in context of patient s complaint Cannot diagnose with RLS, narcolepsy, untreated OSA or REM behavior disorder

32 PLMD Features May be seen in conjunction with RLS Positive family history for RLS increases risk for both RLS and PLMD Medication effects (exacerbation of PLMD) Antidepressants (SSRIs, tricyclics) Lithium Dopamine antagonists

33 Commonality with RLS Low serum ferritin Dopaminergic mechanism Medication responses Medical co-morbidities

34 Differential Diagnosis (PSG) Hypnic jerks Fragmentary myoclonus Normal REM sleep phasic activity Leg cramps Nocturnal epileptic seizures Myoclonic epilepsy Myoclonus of other neurologic conditions Alzheimers, Creutzbeldt-Jakob, etc

35 Treatment PLMD First determine that is a disorder Behavioral measures Reduce caffeine, alcohol, nicotine Ferritin level Medications Dopamine agonists Gabapentin benzodiazepines

36 Conclusions Restless legs are a common condition (all ages) Careful history is key to distinguish from mimics RLS can frequent occur with other sleep disorders Restless legs are NOT periodic limb movements Periodic limb movements are NOT a disorder Must link symptoms with findings Treatment for RLS is available and can improve sleep and quality of life