The Challenges of Treating Restless Legs Syndrome

The following case report appears in this month's Journal of General Internal Medicine (abstract below):
CASE REPORT
Medication Tolerance and Augmentation in Restless Legs Syndrome: The Need for Drug Class Rotation
Roger Kurlan, MD, Irene Hegeman Richard, MD, Cheryl Deeley, RNP
Restless legs syndrome (RLS) is a common condition characterized by an unpleasant urge to move the legs that usually occurs at night and may interfere with sleep. The medications used most commonly to treat RLS include dopaminergic drugs (levodopa, dopamine agonists), benzodiazepines, and narcotic analgesics. We report the cases of 2 patients with RLS who illustrate the problems of tolerance (declining response over time) and augmentation (a worsening of symptoms due to ongoing treatment) that can complicate the pharmacotherapy of RLS. We discuss the optimal management of RLS and propose strategies to overcome tolerance and augmentation such as a rotational approach among agents from different classes.
Tolerance and augmentation (see abstract above for definitions) were significant problems with Sinemet, which was previously commonly used to treat RLS. Tolerance and augmentation are less of a problem with the Requip and Mirapex, two dopamine agonists FDA approved for the treatment of RLS. However augmentation and tolerance still occur with these meds, and there is little research about the best way to deal with this vexing problem. I usually treat RLS initially with Requip or Mirapex monotherapy. If tolerance or augmentation occur, I first add another RLS agent (Neurontin, benzodiazepines, or opioids) and then later switch from 1 opioid agonist to another.