Relief of Urge with Movement of the Affected Body Part
Circadian Pattern: typically with onset in evening or at bedtime
Treatment
General Comments
Impulse Control Disorders
Epidemiology
Impulse Control Disorders Occur in 15% of Patients with Parkinson Disease and Patients Treated with Dopamine Agonists for Hyperprolactinemia
Impulse Control Disorders Have Been Reported in 6-17% Patients Treated with Dopamine Agonists for RLS
Impulse Control Disorders May Occur More Often with Higher Doses of Dopamine Receptor Agonists
Impulse Control Disorders May Occur More Often in Females
Physiology: impulse control disorders probably involves agonism at the dopamine D2 and D3 receptors
Management of Impulse Control Disorders
Decrease Drug Dose and/or Add a Non-Dopaminergic Agent
Long-Term Treatment of Restless Legs Syndrome
Augmentation and Loss of Efficacy are the Main Causes of Treatment Failure Which Emerge Later in the Course of RLS Treatment
Loss of Efficacy Commonly Occurs for All Drugs in the Long-Term Treatment of RLS
Augmentation is a major clinical problem that emerges with the long-term treatment of RLS: it can produce a severe exacerbation of RLS symptoms, and is thus something to be carefully assessed and managed
Some degree of augmentation has been reported with the use of all investigated dopaminergic drugs and also with tramadol
In the virtual absence of direct comparative studies, the incidence rate seems to be highest during treatment with levodopa and higher for shorter-acting (pramipexole, ropinirole) than longer-acting (rotigotine, cabergoline) dopa- mine-receptor agonists
Risk of augmentation increases with longer duration of treatment and possibly with higher doses
Recommendations (International Restless Legs Syndrome Study Group Guidelines, 2013) (Sleep Med, 2013) [MEDLINE]
For Augmentation and Loss of Efficacy, Serum Ferritin Should Be Measured and If <75 μg/mL, Supplementation with Oral Irone is Recommended: unless poorly-tolerated or contraindicated
For Augmentation and Loss of Efficacy, Patient Should Be Queried About Lifestyle Changes, Compliance with the Current Therapy, Changes in Medical Factors (Use of Dopamine Receptor Antagonists or Antidepressants), or Other Extrinsic Factors (Sleep Deprivation, Blood Loss, Alcohol Use)
For Loss of Efficacy, Doses of the Current Agent Should Only Be Adjusted Above the Approved Levels with Caution and with Monitoring for Adverse Effects, Development of Augmentation, or Progressive Loss of Efficacy: instead, consideration should be given to adding another medication or changing medications
For patients experiencing loss of efficacy under monotherapy, a drug of another class (either dopamine-receptor agonists or α2γ ligands) could either be added without increasing the dose of the current drug or, alternatively, substituted for the current drug
Pramipexole is Effective for the Treatment of RLS for Up to 6 mo (Level A Recommendation) and Probably Effective for 1 yr (Level B Recommendation)
Pramipexole is Also Possibly Effective for Up to 10 yrs in the 10–40% of Patients Who Tolerate Therapy and Do Not Experience Augmentation or Loss of Efficacy
Rotigotine is Effective in the Treatment of RLS for 6 mo (Level A Recommendation)*
Rotigotine Also is Probably Effective for Up to 5 yrs in the Approximately 43% of Patients Who Tolerate the Therapy and Who Do Not Experience Augmentation or Loss of Efficacy (Level B Recommendation)
Recommendations (International Restless Legs Syndrome Study Group Guidelines, 2013) (Sleep Med, 2013) [MEDLINE]
Cabergoline/Pergolide
Pergolide and Cabergoline Should No Longer Be Used in the Treatment of RLS, Except for Those Patients Whose Symptoms are Refractory to All Other Treatments and in Whom the Benefits Outweigh the Risks
Patients Who Receive Pergolide and Cabergoline Should Undergo Annual Echocardiogram
Recommendations (International Restless Legs Syndrome Study Group Guidelines, 2013) (Sleep Med, 2013) [MEDLINE]
Benserazide-Levodopa/Carbidopa-Levodopa (Sinemet) (see Carbidopa-Levodopa)
Levodopa is Probably Effective for Up to 2 yrs for the Treatment of RLS in the 24–40% of Patients Who Tolerate Therapy and Who Do Not Experience Augmentation or Loss of Efficacy (Level B Recommendation)
Evidence is Insufficient to Make a Recommendation on the Use of Levetiracetam in the Long-Term Treatment of RLS
Tetrabenazine
Evidence is Insufficient to Make a Recommendation on the Use of Tetrabenazine in the Long-Term Treatment of RLS
References
Frequency of impulse control behaviours associated with dopaminergic therapy in restless legs syndrome. BMC Neurol. 2011 Sep 28;11:117. doi: 10.1186/1471-2377-11-117 [MEDLINE]
The long-term treatment of restless legs syndrome/Willis-Ekbom disease: evidence-based guidelines and clinical consensus best practice guidance: a report from the International Restless Legs Syndrome Study Group. Sleep Med. 2013 Jul;14(7):675-84. doi: 10.1016/j.sleep.2013.05.016 [MEDLINE]
Dopamine receptor agonist drugs and impulse control disorders. JAMA Intern Med. 2014 Dec;174(12):1935-7. doi: 10.1001/jamainternmed.2014.4097 [MEDLINE]
