Assessing, Recognizing Severe Augmentation in RLS

September 26, 2018

The restless leg syndrome expert discussed how general neurologists can best identify and address newly diagnosed patients, as well as what has changed in recent years.

Mark J. Buchfuhrer, MD

In restless leg syndrome (RLS), one of the most difficult, yet fairly common, situations for the treating physician is the presentation of augmentation after medication administration.

For those cases that become severe, the position can be even more problematic to treat. Mark J. Buchfuhrer, MD, a nationally recognized expert in RLS, suggested that some of these issues are caused by a lack of understanding of how to accordingly adjust treatment. And while this is a difficult condition to treat for those who specialize in sleep medicine, for the general neurologist who is unfamiliar with its management it can be a nightmare.

To improve acumen about augmentation in the general neurology community about how to assess and identify the condition, as well as what has changed and what is in development, Buchfuhrer spoke with NeurologyLive.

NeurologyLive: How do you address those patients with severe augmentation?

Right now, if you look at doctors, like myself, who are considered national RLS experts, we all agree that 75% or more of the referrals to us are patients in severe augmentation. Other than that, I see patients who are on 2 mg or 3 mg of Mirapex or Requip. Typically, the only choice that works well then is switching them over to an opioid. This means they’re going to be on the opioid indefinitely and as you can appreciate in this opioid-sensitive climate, or epidemic climate, that’s not as great an option as can be. It works pretty well, but we clearly would like to not have to have that option by treating patients differently initially.

For the general neurologist, what’re your best practices for identifying and assessing augmentation?

For the untreated patient—just got diagnosed, has not been on any prescription drugs for the treatment of RLS. What I would say is number 1, try an alpha-2 delta ligand, which would include gabapentin, Horizant, or Lyrica, first. If these drugs don’t work, have adverse effects, or are not helpful for whatever reason, then I would suggest using the long-acting dopamine agonist, the Neupro patch. If that doesn’t work or causes issues—typically skin reactions—then I would say you can go to the short-acting dopamine agonist drugs, Mirapex and Requip, but use them in the lowest dose possible and definitely do not exceed the recommended daily limits. I would say try to keep it well under the daily recommended limits. In fact, in the books and articles I write, I typically advise not to go over Mirapex at 0.25 mg and Requip 1 mg.

One other trick is if you’re using those drugs or you have a patient already on low-dose Mirapex or Requip, even if gabapentin or Horizant have not been effective on their own in the past, sometimes adding them to a dopamine agonist may make them more effective.

Is there anything in the pipeline for RLS that you’ve kept your eye on?

There are minor things in the pipeline, but nothing major. The only thing that could be very important is that we believe that iron deficiency in the brain is a very significant component of this disorder. Patients should have ferritin levels checked and those should be done while fasting. The only issue with ferritin levels is that it is an acute phase reactant, so if someone has had a cold in the last 2 to 3 weeks, it could make it go falsely up when it really is down. So, check the ferritin and serum iron and iron saturation levels.

If they’re low, iron supplementation, first orally, but to be effective in the majority of patients, use intravenous iron infusions with certain IV iron preparation. Not all of them work that well, there are a few that do. The best 2 are INFeD and Injectafer, and they can often be dramatically helpful in patients. Also, when the iron levels are low, augmentation is more likely. It’s really augmentation and iron. Those are the 2 biggest hot topics in RLS.

Is there anything that’s changed in the past few years with RLS?

In the old days, like 10 to 12 years ago, recognition of the disease was the big issue because the RLS symptoms are so weird that most patients don’t really want to talk about them, or they’ve talked about them and gotten weird looks. But the drug companies have done such a good job in recognition of the disease that patients can typically pick it up on their own and doctors are pretty aware. Think that’s 1 less issue.

We’ve had careful studies over the last decade or 2. Even though the identification is better, a lot of people still are unsure how common it is. Many studies kind of corroborate that if you look, especially at Caucasian and western populations, 10% of adults have RLS. Whether it’s once every several months or daily and bothersome, that is a huge amount. We’ve done studies in both, and in any general practice, 2% of the population have restless legs bad enough that likely need treatment, which makes this a very common problem.

Transcript edited for clarity.