Monday, May 26, 2008

Are your legs restless for relief?

Restless legs syndrome (RLS) has become a popular target for drug therapy. Two popular medications used to treat RLS are levodopa and ropinirol (Requip). Not a whole lot is really known about RLS; therefore treatment algorithms and standards have yet to be consistently used.

Separately from drug treatment, several studies have identified that iron metabolism is abnormal in individuals with RLS. There is some thought that normalizing these imbalances is an important part of treating the syndrome.

However, one group of researchers identified that physicians, rather than doing a comprehensive metabolic/nutritional evaluation and treatment of RLS, tend to jump right into prescribing medication. The treatment protocols for 27, 22 of which were on levodopa and 5 were on ropinirol, were studied after a year of medication treatment.

Severity of symptoms was only documented in 2 of these patients! If you don't create a measurement of baseline, there is no way progress can be measured...and in turn appropriateness of continued medication cannot be determined. This is akin to a person complaining of lightheadedness. Then, without even measuring blood pressure, prescribing an antihypertensive agent and not having any idea of how you're going to decide if the drug of choice was appropriate, effective, or devoid of side effects.

Despite the fact that iron status has been documented to be a significant contributor to restless legs in a fair number of people, serum ferritin levels were not obtained in 18 and transferrin-iron saturation (Tsat) percentages were not obtained in 20 of the study subjects.

An interesting aspect of this study is that 96% of the prescribing physicians were family practitioners. They were not neurologists or psychiatrists, who would be the specialists most likely to have strong experience in treating restless legs, as well as in working with medications used to treat them. This finding is similar when it comes to antidepressants--more than 90% of all scripts for medications in this category are written by family practitioners, not psychiatrists.

Makes you wonder if the burden of what needs to be known in a more generalist type of work such as family practice, places these physicians in a position to know too little about too many things. On the other hand, in my work, when I am asked to provide treatment (or even an opinion, for that matter), about an area of nutrition or medicine about which I am not an expert, I recognize my limits and I refer to someone better equipped to do the right job.

For more information on RLS and iron, please visit this link from the National Institute of Health:

Molokwu OC. Appropriate use of dopamine agonists and levodopa in restless legs syndrome in an ambulatory care setting. Ann Pharmacother. 2008 May;42(5):627-32.

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