Treatment of RLS
Although movement brings relief to those with RLS, it is generally only temporary. RLS can be controlled by finding any possible underlying disorder and treating the associated medical condition, such as peripheral neuropathy or diabetes, will in most cases alleviate many symptoms
Lifestyle changes
For those with mild to moderate symptoms, prevention is the key, and many physicians suggest certain lifestyle changes and activities to reduce or eliminate the symptoms.
Some patients have reported that avoidance of excessive coffee and alcohol, taking cold and/or hot baths, relaxation, acupuncture and massage all have a positive effect on RLS symptoms. However, these efforts rarely succeed in completely eliminating the symptoms.
Mineral supplement
Physicians may suggest that the patients take supplements to correct deficiencies of iron, vitamin B12 and folate. In case of low tissue iron (S-Ferritin < 45 micrograms/l) iron substitution can relieve some symptoms. However, oral iron substitution may not be sufficient and long-term iron substitution is not recommended. In cases where problematic RLS with low S-Ferritin levels do not respond to oral iron, intravenous iron therapy may be considered.
Sleep patterns
Studies have shown that maintaining a regular sleep pattern can reduce symptoms. Patients who experience that their RLS symptoms are minimized in the early morning change their sleep patterns.
Exercise
Others have found that a programme of regular moderate exercise helps them sleep better. However,, excessive exercise, especially in the evenings, has been reported by some patients to aggravate RLS symptoms.
Medication
Dopaminergic agents, also used to treat Parkinson's disease, have been shown to reduce RLS symptoms and PLMs and are considered the initial treatment of choice.
Good short-term results of treatment with levodopa plus carbidopa have been reported, although eventually most patients will develop augmentation (see below) limiting the usefulness of these drugs.
Non-ergolide dopamine agonists such as pramipexole and ropinirole are effective in most patients and are less likely to cause augmentation compared to levodopa.
In the most severe cases other drugs such as antiepileptics (gabapentine or pregabalin), or even benzodiazepines and opioids can be considered. In these cases referral to a specialist should be considered.
Unfortunately, not one drug is effective for everyone suffering from RLS. What may help one person may actually worsen the symptoms for another. In addition, medications taken regularly may lose their effect, making it necessary to change medications periodically.
Augmentation
After weeks or months of treatment some patients develop augmentation which worsen their RLS. Commonly the first sign of augmentation is that symptoms appear earlier in the evening or afternoon, which may lead to an increased dose. This can lead to further augmentation, where the symptoms appear earlier in the day, are more intense (worsened) and may last for a longer time at night. Augmentation should lead to a lowering of the dose of the offending drug, a drug-free period of a few weeks or a change of medication. Referral to a specialist should be considered.
Mistreatment
In lack of a global treatment strategy, a number of different drugs are today prescribed with the expectation of a positive effect on RLS. This includes drugs for muscle cramps and anti-inflammatory analgetics, which have no proven record on treating RLS. It also includes some antidepressants, neuroleptics and H2 blockers, which in fact could all worsen the patients’ condition.
Choosing the right practitioner
In general, it is believed that general practitioners should treat patients with a normal neurological status and an expected response to low dose dopamine agonist. Neurologists should treat patients with atypical presentation, lack of treatment response and patients where high doses are needed.