Pros and Cons of Dopamine Agonists and Other Treatments for Restless Leg Syndrome

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Restless legs syndrome (RLS) patients have to decide whether a drug's benefits will outweigh its risks. The television commercials will certainly tell you: RLS is out there, and so are the pills to treat it. Thanks to aggressive pharmaceutical marketing, doctors, and patients have heard a lot in the past few years about this controversial condition.

RLS is diagnosed when a patient meets four specific criteria; if symptoms are severe enough, medication may help keep them under control. (Milder cases are often treated with lifestyle adjustments, and doctors remain divided as to whether drugs are currently over-or under-prescribed for the condition.)

Dopamine Agonists for Restless Leg Syndrome

Two recent FDA approvals have fueled much of the media hubbub: Requip (generic name ropinirole) and Mirapex (generic name pramipexole), both originally used to treat Parkinson's disease. This class of drugs—called dopamine agonists—activates receptors in the brain that produce dopamine, a chemical that helps regulate movement and mood.

Because RLS seems to be caused by a dopamine shortage in the brain, Requip and Mirapex—taken an hour or two before bed—improve nighttime symptoms in many patients. The two medications work similarly, although patients often respond differently to each. Most doctors use trial and error to find the best medication regimen.

"RLS Medication Helps Me Feel Normal Again" said one patient, Hannah, who hid her restless legs for years, but now she finally has relief.

"We joke in sleep medicine that these drugs are some of our favorites because the patients actually get better," says Mary Susan Esther, MD, former President of the American Academy of Sleep Medicine. "It's so rewarding to treat someone who responds at low doses to a new medicine, especially after they've been suffering for years without it."

In separate studies, patients who took either Requip or Mirapex were more likely to feel improvement over a 12-week period than those who took placebos; both drugs have also been shown to be safe and effective for up to nine months.

Based on these results, the drugs are now advertised to those suffering from moderate to severe primary restless legs syndrome—meaning symptoms that aren't caused by any other known condition, like nerve damage or a vitamin deficiency.

Medications Are Not Without Risk

Dopamine agonists will not work for everyone. They also have a number of common side effects, including nausea and dizziness. But their less frequent side effects—including compulsiveness in gambling, eating, and sexual habits—are an even greater cause for concern.

In 2005 a Mayo Clinic study found 11 cases of patients who had developed gambling habits while taking dopamine agonists for Parkinson's disease. In 2007, three more patients, taking the same medications for RLS, were added to the mix in a newer report. The RLS group included a woman with no previous gambling history who lost more than $140,000.

The gambling urges began, on average, about nine months after patients began taking either Requip or Mirapex, which target motivation, emotion, and reward receptors in the brain. Researchers suggest that anyone taking these drugs be screened for compulsive behaviors and monitored carefully for warning signs.

Still, many patients see these new medications as a miracle treatment. For others, the drugs won't have much effect at all. And even if a certain drug works initially, it can stop working after several months or years.

This process, called augmentation, makes conditions like RLS frustratingly difficult to treat long-term. Symptoms can return worse than they were originally, and patients often have to change doses, switch drug classes, or take a drug holiday to eventually get relief again.

Traditional Sleep Aids May Also Help

Luckily, dopamine agonists aren't the only option for RLS sufferers: Older (and often cheaper) drugs, including anticonvulsants, opioids, and hypnotics such as benzodiazepines and nonbenzodiazepines, may also be used to treat symptoms. Because sleep deprivation can make RLS worse, treating an underlying cause of insomnia or sleep apnea may be the best way to calm your symptoms.

RLS patients often go through several doctors and treatment options until they find one that works for them. All drugs come with risks, so you'll have to decide with your doctor which medication, if any, is the right choice.

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