New concepts in the management of restless legs syndrome
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j104 (Published 27 February 2017) Cite this as: BMJ 2017;356:j104
All rapid responses
There is a peer-reviewed study by Richard P. Allen et al. that demonstrates a clinically significant relief to RLS patients by the use of intravenous iron injection (https://www.ncbi.nlm.nih.gov/pubmed/27823710). We have found similar results using ferric catrboxymaltose in a case study with benefits extending out to 27 months post single intravenous infusion of FCM.
Competing interests: No competing interests
There is reason to believe that the figure of 40% for augmentation rates quoted by Garcia-Borreguero and Cano-Pumarrega in this article seriously underestimates the risk of side effects with long term drug treatment for RLS.
Garcia-Borreguero was Chair and Member of the Writing Committee of the Task Force of the IRLSSG which produced a White Paper on Augmentation in 2015. This paper quoted a study that “estimated that 76% of all patients treated with dopamine agonists showed indication for augmentation, with a yearly incidence of 8%”
In other words three-quarters of patients prescribed dopaminergics will find that their symptoms get worse over time, whatever the short term improvement.
Augmentation is only one of the problems with the dopaminergics, as Paul Morrish points out in his response drawing attention to the increased risk of Impulse Control Disorders (ICD) with dopaminergics.
The list of side effects associated with the ligands - “the initial treatment of choice” - is also long and scary and includes, with Pregabalin, suicidal ideation.
Is there another way?
Yes, but it is not mentioned in this review. Garcia-Borreguero and Cano-Pumarrega make a passing nod at lifestyle modification in the management of RLS/WED, but do not mention at all other non-drug physical and manual therapies.
‘Positional release manipulation’ - the specific osteopathic treatment described in the CARL Trial appears to give long lasting relief of symptoms, without any risk of side effects.
As a Medical Practitioner, trained in Osteopathic Medicine and Western Medical Acupuncture, I run a private clinic for the management of RLS symptoms without medication. Many of these patients have had symptoms for 20 or 30 years, and most score as ‘severe’ or ‘very severe’ on the IRLSS rating scale. In my experience most will have a marked improvement in their symptoms within a few treatments using positional release manipulation.
Competing interests: No competing interests
I have had restless legs at night (perhaps a very mild form of the syndrome) in the past, but am rarely troubled buy it now. I found it was very helpful to stretch my hamstrings (by touching my toes with straight knees) on retiring and if I have to get up in the night; I would recommend this as being well-worth a try for anyone troubled with the syndrome.
Competing interests: No competing interests
I did not know what alpha 2 delta ligands were, either - not helpful, in what was otherwise a good review. These are off licence in RLS, which it would also have been useful to note.
Competing interests: No competing interests
What is missing from this article? A treatment with no side effects and demonstrated to be more effective than drugs is a osteoppathic techqniue, not requiring any manipulation, using a osteopathic techqniue called "Strain Counter Strain". http://www.tandfonline.com/doi/abs/10.1179/1753615412Y.0000000011
As Medical Osteopath and General Practitioner I use this techqniue effectively for my NHS patients and the London College of Osteopathic Medicine offers charitable treatment for patients with RLS. This article in the BMJ does demonstrate the difficulty of raising awareness in medicine of effective non drug treatments with our medical colleagues.
Competing interests: London College of Osteopathic Medicine offers treatment for Restless Legs Syndrome. The London College of Osteopathic Medicine is one of the osteopathic schools and also runs a charitable clinic offering osteopathic treatments
Maybe i am just behind the time but I was not aware that the new name for gabapentinoids was alpha2 delta ligand.
Quite hard to find the evidence of significant here also at a time where I think the NEJM had now come out that this class does not work in sciatica. They are already well know as medications of abuse. In my view a key element in this troublesome condition is first do no harm. Anecdotally for reasons I cant understand a combination of white wine and cheese gives it to me but rarely suffer without this combination
Competing interests: No competing interests
It is surprising that the print version of this review does not include the information (that is in the on-line version) that Impulse Control Disorders have been reported to develop in 6-17% of patients with RLS who are being treated with dopamine agonists. The authors tell us that 2-3% of European adults experience moderate to severe symptoms, and so as many as 60,000 adults in the UK could be affected by ICDs. ICDs include such harmful behaviours as hypersexuality, compulsive shopping and gambling. They are often concealed and frequently lead to misery. It is essential that potential prescribers of these drugs, and their patients, are alert to this devastating ill effect.
Competing interests: No competing interests
Re:Managing Restless Legs Syndrome: State of The Art Review
We were surprised that a review entitled "Managing Restless Legs Syndrome" had no primary care contributing author. As a medical student and a senior GP we would suggest that the recent welcome emphasis on improving recruitment to primary care should include ensuring that reviews of conditions, like restless leg syndrome, which are commonly seen and treated in primary care include primary care authors.
Whilst a discussion of new concepts in the treatment of such conditions is interesting and valuable, many patients do not need new treatments. The review article refers to much more expensive dopamine agonists but does not mention the cost effective first line use of low dose co-beneldopa, which one of us has used for many patients over many years.
Whilst augmentation and loss of efficacy are recognised issues with the use of dopamine agonists, experience has shown that intermittent use of these drugs can avoid these problems. The addition of a GP author in such reviews might ensure that cost is a consideration.
Routinely including at least one GP author in articles about common conditions presenting in primary care would both improve the relevance of reviews and perhaps encourage medical students to consider this interesting and rewarding branch of medicine as a career.
Competing interests: No competing interests