Q. Your last column mentioned that medications such as ropinirole and pramipexole are not longer suggested for restless legs. Why is that and are there other medications that can be tried?
A. Yes, in our last Ask the Pharmacist column, we hinted at a new study reported by the American Academy of Sleep Medicine that revealed that dopamine agonists (ropinirole, pramipexole) should no longer be the first medications tried for restless legs syndrome (RLS). Despite many people being affected with RLS for decades, it is still not fully understood but the thought is that it involves lower dopamine levels in the brain.
Therefore, it makes sense that dopamine agonists (which mimic/ act like dopamine) should be tried to help minimize your symptoms. However, long-term use of these dopamine agonists are associated with an augmentation (worsening) of your symptoms as well as their common side effects such as nausea, drowsiness, hallucinations and compulsive behaviours among others. When the symptoms worsen while taking these dopamine agonists, people might wish to increase their dose. This may help for a short period of time but the worsening of your symptoms will once again catch up with you and you will find yourself in the same boat. That said, some people may still want to consider these dopamine agonists at their lowest effective dose for just a few weeks to help with RLS during periods of restricted activity such as a long plane flight or long car rides etc…, if those are the only times your RLS affects you. But you may still have to contend with the side effects mentioned above.
We also discussed the common triggers that can worsen RLS in our last column. Once you have reviewed them and made adjustments to your lifestyle to help reduce your RLS, you may still be looking for something to help alleviate your symptoms. We spoke about low iron/ferritin levels being strongly correlated with RLS. If you haven’t done so already, everyone with RLS should request a serum iron including ferritin and transferrin saturation levels and supplement with an iron tablet if it proves to be low. It is important to ensure you are low in iron before you consider supplementing as too much iron is also problematic to your health.
If your symptoms continue to be bothersome after addressing your triggers and potential iron deficiencies, then a trial of the GABAergic agents (gabapentin, pregabalin) is warranted. These tend to reduce the severity of your RLS and do not worsen your symptoms if taken long-term. They can cause significant drowsiness so it is recommended to take these GABAergic agents in the evening (best a few hours before bedtime for RLS) and to start at a low dose. The dose can be slowly increased every few days as tolerated until you achieve some benefit. There isn’t one GABAergic agent that is better than another but some may find that one works better for them. If you try one and find it does not work well for you, consider asking for another GABAergic agent to try.
At one time, benzodiazepines (such as clonazepam, lorazepam or any other drug ending in “pam”) were commonly recommended but are no longer suggested due to the lack of evidence supporting their effectiveness and their risk of dependency and/or addiction.
Some people experience significant pain with RLS and may consider asking for strong pain killers such as opioids. These should only be considered as a last resort. They are not suggested to use as a first or second line but when all other attempts at reducing your RLS symptoms, that might be an option to help easy your discomfort.
For more information on this or any other health related topic, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination.
