Tuesday, August 30, 2005

Restless Leg Syndrome

Below is a collumn about restless leg syndrome that I wrote for the newsletter of the Mississippi Psychiatric Association newsletter:
It’s summer and time for vacation! Although the time spent at the vacation destination is usually pleasant, long car and airplane trips can be tedious. For those with restless leg syndrome, these trips can be pure misery.
Restless leg syndrome (RLS) is characterized by an urge to move the legs, usually accompanied by disagreeable/uncomfortable leg sensations. These sensations, often described as "creeping" or "crawling," are typically perceived in the calves, but can also involve other parts of the lower extremities, and in more severe cases, can involve the upper extremities. RLS is worse in the evening/night and in sedentary situations such as long car rides. The symptoms often interfere with sleep. Vigorous movement improves RLS symptoms. Response to a dopaminergic drug is considered to be supportive of the diagnosis.
Approximately 10% of the population has at least mild, intermittent symptoms of RLS; about 3% of the population has moderate to severe symptoms.
RLS can be idiopathic, familial (often inherited in an autosomal dominant pattern), or secondary. Common secondary causes of RLS include iron deficiency, pregnancy, uremia, and neuropathy. RLS has also been reported to occur in association with folate, B12, and magnesium deficiencies. Many psychiatric medications, including dopamine antagonists, serotonergic antidepressants, and lithium, can unmask or worsen RLS. Wellbutrin, however, does not worsen RLS. Wellbutrin, due to its dopaminergic properties, has been speculated to improve RLS, but data is lacking.
RLS is diagnosed based on history; polysomnography is not necessary or indicated for diagnosis, though in most cases periodic leg movements occur during sleep. The differential diagnosis includes nocturnal leg cramps, neuropathy, akathisia, and vascular disease. The most important lab test to check in someone with restless leg syndrome is a ferritin level. Iron supplementation should be administered to keep the ferritin level above 50.
RLS is commonly treated with dopaminergic agents. Requip (ropinirole) is the first and only FDA-approved medication for the treatment of moderate-to-severe primary RLS. Mirapex (pramipexole) is also commonly used. Ergot-derived medications, such as pergolide, should be avoided due to the risk of cardiac valvuopathy. Sinemet can be used for short-term treatment or to confirm the diagnosis, but has a higher risk of augmentation than the other dopaminergic medications. Augmentation is the shifting of symptoms to several hours earlier than was typical before pharmacologic intervention. Other medications used to treat RLS include benzodiazepines, opioids, and gabapentin.
RLS is a common, unpleasant condition that can be unmasked or worsened by many psychiatric medications. Its prevalence in the psychiatric population is probably higher than in the general population. In cases in which the diagnosis is uncertain or in which the psychiatrist feels uncomfortable treating RLS, referral to a sleep specialist or a neurologist is indicated

Tuesday, August 23, 2005

Missouri Medicaid Cuts CPAP coverage

From the National Sleep Foundation:
Effective September 1, 2005, Missouri Medicaid will no longer cover many kinds of durable medical equipment (DME), including positive airway pressure (PAP or CPAP) devices which are the mainstay of treatment for obstructive sleep apnea.
NSF Chairman,
Barbara Phillips, MD, MSPH, explained, "This is a dangerous public health decision, not just for the 1 in 20 Missourians who have sleep apnea, but also for those on the roads and in the cars with them." Sleep apnea causes adverse or worsens many health problems, including hypertension, cardiovascular disease, diabetes, cognitive impairment and cerebrovascular accidents. CPAP treatment is effective in reversing these consequences. More important for all Missourians, however, is the fact that untreated sleep apnea results in automobile crashes; the risk of this is normalized with CPAP treatment. Budgetary limitations are a sad fact of life, but it's important to know that the cost of care of patients with sleep apnea goes down after CPAP treatment is initiated. The decision to eliminate coverage of DME passed by the Missouri State Legislature in Senate Bill 539 endangers the health of all Missourians, and will likely cost more money in the long run if enacted. Sleep Health Advocates are urged to contact their legislators if they are Missourians (www.moga.state.mo.us/) as well as the Missouri Medicaid Offices.
Learn more here.