How does Benadryl affect restless legs syndrome. What are the triggers for RLS symptoms. Can antihistamines worsen restless legs syndrome. What are alternative treatments for RLS. How to manage restless legs syndrome effectively.

The Link Between Benadryl and Restless Legs Syndrome

Restless Legs Syndrome (RLS) is a neurological disorder characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations. Many people with RLS have found that certain medications, including the common antihistamine Benadryl (diphenhydramine), can exacerbate their symptoms.

Why does Benadryl trigger RLS symptoms? Diphenhydramine, the active ingredient in Benadryl, is known to affect the dopamine system in the brain. Dopamine plays a crucial role in controlling muscle movement and is believed to be involved in RLS. By interfering with dopamine signaling, Benadryl can potentially worsen RLS symptoms in susceptible individuals.

Common Medications That May Aggravate RLS

• Benadryl (diphenhydramine)
• PM pain medications containing diphenhydramine
• Certain nausea medications (e.g., Phenergan)
• Some antidepressants
• Anti-nausea drugs
• Antipsychotic medications

It’s important for RLS sufferers to be aware of these potential triggers and to inform their healthcare providers about their condition when discussing medication options.

Recognizing and Managing RLS Symptoms

RLS symptoms typically include:

• An overwhelming urge to move the legs
• Uncomfortable sensations described as crawling, itching, or throbbing
• Relief of symptoms with movement
• Worsening of symptoms during rest or at night

How can RLS symptoms be managed effectively? While avoiding trigger medications is crucial, there are several other strategies that can help alleviate RLS symptoms:

1. Regular exercise
2. Maintaining a consistent sleep schedule
3. Reducing caffeine and alcohol intake
4. Practicing relaxation techniques
5. Using heat or cold therapy on the legs
6. Taking iron supplements if deficient (under medical supervision)
7. Considering prescription medications specifically for RLS

The Importance of Patient Advocacy in RLS Treatment

Many RLS sufferers have found that their healthcare providers are not always aware of the connection between certain medications and RLS symptoms. This highlights the importance of patient advocacy and self-education. How can patients effectively communicate their RLS concerns to healthcare providers?

• Keep a symptom diary to track triggers and patterns
• Bring informational materials about RLS to appointments
• List RLS-triggering medications as “allergies” in medical records
• Seek out healthcare providers experienced in treating RLS

The Connection Between Thyroid Function and Digestive Issues

While seemingly unrelated to RLS, an interesting connection between thyroid function and digestive issues has been observed in some patients. Hypothyroidism, a condition characterized by an underactive thyroid gland, can sometimes lead to low stomach acid (achlorhydria). This can cause digestive symptoms that may be mistaken for excess stomach acid.

In some cases, treating the underlying thyroid condition with natural desiccated thyroid (NDT) has resolved digestive issues and eliminated the need for proton pump inhibitors (PPIs). This underscores the importance of considering thyroid function in patients with persistent digestive complaints.

Beta Blockers and Quality of Life: Finding the Right Balance

Beta blockers, while effective for treating high blood pressure in some patients, can significantly impact quality of life for others. Common side effects include fatigue, slow heart rate, and decreased exercise tolerance. These effects can be particularly pronounced in older adults or those with active lifestyles.

A patient’s experience of gradually reducing atenolol dosage while maintaining blood pressure control with an ACE inhibitor (perindopril) illustrates the importance of individualized treatment approaches. How can patients work with their healthcare providers to optimize their blood pressure treatment?

• Regularly monitor blood pressure and heart rate
• Keep a log of side effects and quality of life impacts
• Discuss alternative medication options with healthcare providers
• Consider lifestyle modifications to support blood pressure control

Allergy Season and Its Impact on RLS

The connection between allergy season and RLS symptoms is an area of growing interest. While antihistamines like Benadryl can exacerbate RLS, the allergies themselves may also play a role in symptom flare-ups. How might allergies affect RLS?

• Disrupted sleep patterns due to allergy symptoms
• Increased inflammation in the body
• Potential changes in neurotransmitter levels
• Stress and anxiety associated with allergy symptoms

Managing allergies effectively without relying on RLS-triggering medications becomes crucial for those with both conditions. What are some allergy management strategies for RLS sufferers?

1. Non-sedating antihistamines (consult with a healthcare provider)
2. Nasal saline rinses
3. Air purifiers in living spaces
4. Allergen avoidance strategies
5. Immunotherapy (allergy shots or sublingual tablets)

Holistic Approaches to Managing RLS and Related Conditions

Given the complex interplay between RLS, allergies, thyroid function, and cardiovascular health, many patients are turning to more holistic approaches to manage their symptoms. What are some integrative strategies that may benefit individuals with RLS and related conditions?

• Acupuncture
• Massage therapy
• Mindfulness meditation
• Yoga or tai chi
• Herbal supplements (under medical supervision)
• Dietary modifications
• Cognitive behavioral therapy for sleep

It’s important to note that while these approaches can be beneficial, they should be pursued in conjunction with, not in place of, conventional medical care. Always consult with healthcare providers before starting new treatments or supplements.

The Future of RLS Research and Treatment

As our understanding of RLS continues to evolve, new avenues for research and treatment are emerging. What are some promising areas of investigation in the field of RLS?

• Genetic studies to identify RLS risk factors
• Advanced neuroimaging to better understand brain activity in RLS
• Development of more targeted medications with fewer side effects
• Investigation of the gut-brain axis in RLS
• Exploration of non-invasive neuromodulation techniques

These research directions hold the potential to improve diagnosis, treatment, and quality of life for individuals living with RLS. As we await these advancements, what can patients do to stay informed and engaged in their RLS care?

1. Join RLS support groups or online communities
2. Participate in clinical trials when available
3. Stay up-to-date with the latest RLS research
4. Advocate for increased RLS awareness and research funding
5. Work closely with healthcare providers to optimize treatment plans

By taking an active role in their care and staying informed about the latest developments, individuals with RLS can improve their symptom management and overall quality of life.

Navigating the Challenges of RLS in Daily Life

Living with RLS can present unique challenges in various aspects of daily life. How can individuals with RLS adapt their routines and environments to minimize symptom impact?

Work Environment Adaptations

• Use standing desks or adjustable workstations
• Take regular movement breaks
• Consider compression socks for prolonged sitting
• Discuss flexible scheduling options with employers

Travel Strategies

Traveling with RLS can be particularly challenging due to prolonged periods of inactivity. What strategies can help manage symptoms while on the go?

1. Choose aisle seats on planes or trains for easy movement
2. Pack a travel kit with RLS relief items (e.g., massage roller, hot/cold packs)
3. Plan rest stops during road trips for stretching and walking
4. Maintain medication schedules across time zones

Sleep Environment Optimization

Creating a sleep-friendly environment is crucial for RLS management. How can individuals optimize their bedrooms for better sleep?

• Invest in a comfortable, supportive mattress
• Use breathable, temperature-regulating bedding
• Install blackout curtains to minimize light disturbance
• Consider using a white noise machine to mask disruptive sounds
• Keep the bedroom cool and well-ventilated

Social and Relationship Considerations

RLS can impact social interactions and relationships, particularly when symptoms interfere with shared activities or sleep. How can individuals with RLS navigate these challenges?

1. Educate friends and family about RLS to increase understanding
2. Be open about limitations and needs related to RLS
3. Plan activities that accommodate movement breaks
4. Consider separate sleeping arrangements if nighttime symptoms disrupt a partner’s sleep

By implementing these strategies and maintaining open communication with loved ones, individuals with RLS can better manage their symptoms while maintaining a fulfilling social life.

The Role of Diet and Nutrition in RLS Management

While the exact relationship between diet and RLS is still being studied, many individuals have reported that certain dietary changes can impact their symptoms. What nutritional strategies might be beneficial for RLS management?

Key Nutrients for RLS

• Iron: Essential for dopamine production
• Magnesium: May help relax muscles and reduce cramping
• Vitamin D: Deficiency has been linked to increased RLS symptoms
• B vitamins: Support overall nervous system health

It’s important to note that while these nutrients may be beneficial, supplementation should only be done under medical supervision, particularly in the case of iron.

Dietary Considerations

What dietary changes might help alleviate RLS symptoms?

1. Reduce caffeine intake, especially in the evening
2. Limit alcohol consumption
3. Avoid large meals close to bedtime
4. Stay hydrated throughout the day
5. Consider a Mediterranean-style diet rich in fruits, vegetables, and lean proteins

Potential Trigger Foods

Some individuals with RLS have reported that certain foods may trigger or worsen their symptoms. While these triggers can vary from person to person, common culprits may include:

• Processed foods high in sugar or artificial additives
• Foods containing MSG (monosodium glutamate)
• Excessive sodium intake
• Chocolate (due to caffeine content)

Keeping a food diary can help identify potential dietary triggers and inform personalized nutritional strategies for managing RLS symptoms.

Innovative Therapies and Technologies for RLS Relief

As research into RLS continues, new therapies and technologies are emerging to help manage symptoms. What are some innovative approaches showing promise in RLS treatment?

Neurostimulation Devices

• Transcutaneous electrical nerve stimulation (TENS) units
• Vibrating pads or wraps for the legs
• Portable neurostimulation devices designed specifically for RLS

Wearable Technology

How can wearable devices help individuals with RLS?

1. Track sleep patterns and RLS symptoms
2. Provide real-time feedback on leg movements
3. Offer guided relaxation exercises
4. Deliver targeted vibration or compression therapy

Virtual Reality and Biofeedback

Emerging research is exploring the potential of virtual reality and biofeedback techniques in managing RLS symptoms. These technologies may help:

• Distract from uncomfortable sensations
• Teach relaxation and mindfulness techniques
• Provide visual feedback on muscle tension and relaxation

While many of these innovative therapies are still in the early stages of research or development, they offer exciting possibilities for future RLS management strategies.

As we continue to learn more about RLS and its complex interactions with other health conditions and medications, it’s clear that a multifaceted, personalized approach to management is key. By staying informed, working closely with healthcare providers, and exploring a range of treatment options, individuals with RLS can improve their symptoms and quality of life. The future holds promise for even more effective treatments and a deeper understanding of this challenging condition.

Restless legs episode triggered by common antihistamine

Michael Hastings

Q: One parent and all of my siblings have restless legs syndrome. So do I.

Benadryl, specifically its primary ingredient diphenhydramine, absolutely aggravates my RLS. I avoid it and anything else that contains it, such as the PM pain medications.

Certain nausea medications also make RLS worse. The one I recall is Phenergan.

Don’t assume your physician knows this. Several doctors I spoke with knew nothing about it. As far as I’m concerned, I’m allergic to these drugs, and list them in my records accordingly.

Answer: Restless legs syndrome (RLS) is characterized by an urgent feeling that you need to move your legs. Moving them alleviates sensations of crawling, itching or throbbing, but this frequently keeps people awake. You are quite right that diphenhydramine can aggravate RLS symptoms (National Institute of Neurological Disorders and Stroke). We think people who take PM pain relievers containing diphenhydramine should be alerted to this potential reaction.

People are also reading…

Q: I was diagnosed with Barrett’s esophagus after years of daily PPI use. My then-gastroenterologist had prescribed it. However, what I thought was excess stomach acid as the cause for my indigestion, ironically, was low stomach acid. I believe this was caused by my hypothyroid condition.

My integrative cardiologist subsequently diagnosed the thyroid problem and prescribed natural desiccated thyroid (NDT). My Barrett’s esophagus cleared up and I no longer need a PPI at all. I control my digestive upsets with diet, hydrochloric acid pills, digestive enzymes and a commercial antacid if I really need it.

Answer: Thank you for alerting us to the link between hypothyroidism and achlorhydria. This is the medical term for low stomach acid. Although this is documented in the medical literature, we suspect that most people are unaware of the connection (World Journal of Gastroenterology, June 21, 2009).

Desiccated thyroid gland can be used to treat hypothyroidism. It supplies both T3 and T4 thyroid hormones.

Q: Thank you for writing about beta blockers making you feel like rubbish. I was diagnosed with high blood pressure eight years ago (140/80). My doctor prescribed atenolol.

It did NOTHING for my blood pressure, so after a couple of months my GP added perindopril. WOW! My blood pressure went to 120/70 in two days.

In the meantime, my heart rate that was formerly 80 or 90 BPM was now at 60 or less. Any task was so tiring! I have now passed 60 years of age and I could barely split wood.

When I realized this might be due to the atenolol, I halved the dose for two weeks, then halved it again for another two weeks. Now, a month later, my resting heart rate is back to 80. My blood pressure is 125/75 thanks to the perindopril. I can split wood, walk and even run again. For the past eight years on the beta blocker, I felt like I would pass out if I tried to run. Cheers from Australia.

Answer: Perindopril (Aceon) is an ACE inhibitor and is considered a first-line blood pressure treatment. Beta blockers, on the other hand, are no longer deemed the best choice for blood pressure control. They can cause fatigue and slow heart rate.

You can learn more about these medications and other approaches to manage hypertension in our Guide to Blood Pressure treatment. It is available at www.PeoplesPharmacy.com.

King Features Syndicate

Questions for Joe and Teresa Graedon can be emailed via their website: www.Peoples Pharmacy.com.

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Allergy Season and Restless Leg Syndrome

April 8, 2016 By Admin

By Henry Ehrlich

We pay a good deal of attention to the intersection of allergies and sleep disturbance around here, and it has popped up again.

Years ago I co-wrote a book called Sleep to Save Your Life with sleep specialist Dr. Gerard T. Lombardo that had a chapter called “Restless Legs—Pain in Motion.” I had never heard of it till I worked with Dr. Lombardo, but I can’t forget it. The chapter began with an account of a patient who disobeyed the instructions to bring all his accustomed props to the sleep lab for an overnight study because he was embarrassed to bring a piece of wood the size of a baseball bat and use it to pound his legs while hooked up to electronic monitors under the gaze of a video camera. Restless leg patients frequently resort to inflicting pain on themselves to relieve the pain from within—described variously as aching, burning, cramping, and “creepy crawly” sensations as from bugs or worms. Clearly, this is not Steve Martin’s “happy feet.”

By coincidence, just about the same time we worked on the book, commercials started popping up on TV for a drug to treat it. Since most of my friends had never heard of the ailment restless leg syndrome, or RLS, they tended to dismiss it as one more contrivance by the pharmaceutical industry to monetize an annoying but not serious problem. That drug no longer seems to pop up on TV.

However, RLS has not gone away. The American Sleep Association estimates that it afflicts 12 million Americans. An article that popped up in my news feed the other day mentioned that William Ondo, M.D., a Houston Methodist neurologist, thinks it’s a bigger problem for those with seasonal allergies. Double jeopardy may be impermissible as a matter of law, but for those with RLS, symptoms get worse during allergy symptoms if patients take diphenhydramine—Benadryl–and other first-generation antihistamines at night, drugs that are normally sedating (do not drive or operate heavy machinery).

The reason that Benadryl is sedating for most of us is precisely because it passes the brain-blood barrier where it suppresses brain histamine, a neurotransmitter that is at high levels during the day and crucial for keeping us alert. It down regulates at night, allowing us to sleep. But with RLS it seems to have a paradoxical effect.

Apparently RLS is fairly common among kids with atopic dermatitis: “Awakenings as a result of scratching can be brief or long, and many children with AD have a comorbid diagnosis of restless leg syndrome apparently secondary to itch-induced movements.  Restless leg syndrome is diagnosed clinically as an unrelenting urge at night and before sleep onset to move the legs. Children with AD are also often given a diagnosis of periodic leg movement disorder, which is defined by the presence of repetitive limb movements that, in contrast to restless leg syndrome, only occur during sleep and not before sleep onset.”

What a drag. Parents resort to Benadryl to relieve their children’s maddening itching at night when cortisol levels are low, and get blindsided by RLS.

For these children, newer, non-sedating antihistamines such as loratadine [Claritin] and cetirizine [Zyrtec] are preferable to Benadryl. According Ondo, “We don’t yet understand why sedating antihistamines worsen restless legs syndrome, but we do know that non-sedating antihistamines do not affect the symptoms as much because they do not enter the brain as easily.”

I posed this problem to our contributor, Jessica Dabler Martin, PhD neuroscientist who found a 2009 article that elucidates some of the research on histamine and RLS, which is inconclusive on the specific pathways involved. She observes, “I’m just amazed at how little this has been looked at even though the association has been there for some time! The study referenced from Hopkins was a poster abstract at a neuroscience meeting from 2008, but it appears they never went on to fully publish the results.

“Once again, all of this shows that the same molecule – histamine in this case – can have many different functions throughout the body. The nervous and immune systems overlap yet again.”

Thanks, Jessica.

So, once again sleep disturbance and allergies collide. Poor sleep takes the fun out of waking life, not to mention overall good health. There’s a good reason that sleep deprivation is a form of torture.

Photograph: sandhillneurologists.com

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Filed Under: Editor’s Notes Tagged With: atopic dermatitis, Benadryl, ceterizine, Claritin, diphenhydramine, eczema, loratadine, restless leg syndrome, RLS, Steve Martin, Zyrtec

Restless Leg Syndrome

Restless Leg Syndrome is a condition characterized by discomfort in the legs that occurs at rest and causes a desire to move the legs.

General information

Restless legs syndrome occurs at any age, including children.

Causes of restless legs syndrome:

• iron deficiency anemia,
• pregnancy,
• kidney failure
• diseases of the nervous system
• diabetes mellitus,
• amyloidosis,
• stomach surgery,
• deficiency of vitamin B12, folic acid, thiamine, magnesium,
• alcoholism,
• chronic lung diseases,
• thyroid disorders,
• rheumatoid arthritis;0015
• stress,
• intense physical activity,
• abuse of caffeinated drinks,
• drugs (lithium, nifedipine, etc.) .

  A case from practice prompted me to cover this topic. A young woman asked me to pick up a remedy for her insomnia. When clarifying the details, it turned out that her own husband prevented her from sleeping, who several times during the night shuddered violently or even kicked her legs. I told the woman about Restless Leg Syndrome, gave her recommendations, and asked her to report the results. About two weeks later, she called and said that she now sleeps peacefully. The husband, however, refused to be examined by a doctor, but began to visit the gym several times a week, douse himself with cold water and massage his legs before going to bed. Comprehensive measures have brought a tangible result – the family sleeps peacefully.

  Symptoms

  Discomfort in the legs can be felt as itching, burning or tingling, a feeling of “goosebumps”, a feeling of fullness or, conversely, squeezing. These sensations are usually felt in the depths of the legs, sometimes extending to the thighs, arms, torso. Discomfort in the legs decreases with active movement, massage, warmth. Restless legs syndrome occurs or worsens in the evening and at night, making it difficult to fall asleep. During sleep, many patients experience periodic leg movements (from the outside, these movements may resemble shudders, kicks).

  Treatment of Restless Leg Syndrome

  Treatment of Restless Leg Syndrome is successfully done by non-drug methods:

  • do exercises every day
  • go to bed and wake up at the same time
  • limit food intake at night
  • Two hours before bedtime, give up drinking coffee, tea, alcohol, and any other tonic products
  • soak your feet or take hot water baths before going to bed (some people, on the contrary, cold water helps, so experiment)
  • before going to bed, massage your feet with your hands or using massagers
  • at night, activities with increased mental activity (video games or computer work, drawing, watching TV) are not recommended

  You can drink a course (2-4 weeks) of herbal sedatives ( motherwort, valerian, evasive peony, oregano, fireweed, hops, novo-passit, persen, phytonosed, etc. )

  Usually, following the above recommendations helps to completely cope with restless legs syndrome. If this is not enough, then drugs are included in the treatment of restless leg syndrome. The most commonly used is Mirapex (pramipexole). The advantage of this drug lies in small dosages and antidepressant properties.

  Other drugs (clonazepam, alprazolam, nozepam, carbamazepine, lamotrigine) may be used, but their effectiveness is rather moderate.

  Restless legs syndrome: an underestimated problem and modern possibilities of pharmacotherapy

  It is necessary to treat with medicine
  when it is impossible not to treat.
  B.E. Watchal

  Unfortunately, there are no laboratory tests that can confirm the presence of restless leg syndrome (RLS). To date, no specific disorders of the nervous system characteristic of this disease have been identified. Outside of periods of exacerbations, the patient usually does not show any disorders. Moreover, during the day, symptoms are often absent when contact with a doctor occurs. And those complaints that patients make are not taken seriously. The most valuable in terms of diagnosis are a detailed history and understanding of the essence of the disease, which in most cases are neglected.

  Complaints of patients about discomfort in the legs, accompanied by insomnia, are considered insignificant symptoms for assessing the presence of a serious illness in a patient. This leads to the fact that this category of patients “migrate” from doctor to doctor for many years, remaining without a diagnosis, despite the presence of a kind of curable disease. In fact, all this is an underestimated problem that requires modern pharmacotherapy.

  The importance of the problem of RLS is evidenced by the annual international congresses on this disease [9], the purpose of which is to discuss the key points in the management of these patients that have a significant impact on the quality of life of such patients. And on May 18–19, 2012, in Odessa, under the auspices of the Association of Movement Disorders, international courses on the topic “Restless Legs Syndrome” were held.

  Historical information

  The first characterization of RLS comes from Thomas Willis, an English physician and researcher. For the first time in the medical literature, he presented a case of periodic violent movements in the legs that disturbed sleep. This description almost completely coincides with modern diagnostic criteria for this disorder [25].

  Almost 300 years later, the Swedish researcher Karl-Axel Ekbom [15] developed these criteria. His merit is not only in the scientific definition of the diagnostic symptoms of RLS, but also in the shift in emphasis from movements to the sensory aspects of the disorder. The latter are both the main feature of the disease and the main complaint of patients. He first described both severe, mild parasthetic forms of the disease and cases of the painful form, which he combined under the name restless legs, later adding the term “syndrome” (RLS), denoting a collection of certain symptoms rather than a specific or unitary pathophysiology of the disease.

  Prevalence

  The frequency of this syndrome in the population, according to different authors [1, 6–8, 11, 14], ranges from 2 to 15%. An increase in the incidence of the syndrome with age was also noted [23]. At the age of over 65 years, it is observed in 10–30% of cases [14, 18]. RLS is more common in the United States and Northern European countries, less common in the Mediterranean countries of the Middle East and Asia (0.1–0.7%) [8]. We did not find data on the frequency of RLS in Ukraine in the available literature. Although the incidence increases with age, it can also occur in children. About 1/3 of adult patients believe that the first symptoms of the disease appeared in them before the age of 10 years. It is assumed that at an early onset (before 45 years) the disease progresses slowly and is characterized by a milder course, and at a later onset and advanced age it rapidly progresses to severe forms [2, 7, 8, 11].

  Research conducted in Canada showed that 15% of respondents feel “restless legs” during sleep. And 10% reported that “discomfort in the muscles of the legs” leads to waking up at night, the need to immediately move the legs and the desire to walk [14].

  After reaching the age of 70–79 years, the number of primary cases of the disease decreases. The general impression is that even under the best conditions of awareness of physicians (both in general practice and specialists) regarding the syndrome, the correct diagnosis is made in less than 25% of patients [2, 11, 12, 14]. The incidence prevails in women (more than 2.5 times) [11].

  Causes

  Most authors [1, 2, 6–8, 11, 14, 17] distinguish between primary (idiopathic) and secondary (symptomatic) RLS. Idiopathic RLS occurs in the absence of any somatic or neurological disease, usually at a young age and in most cases has a positive family pattern, which may indicate the role of a genetic factor in the occurrence of this variant of the disease [2, 6, 8, 17]. The nature of inheritance is not yet clear. However, there are indications of both monogenic and polygenic variants of inheritance. In some cases, common loci are found at 9-th, 12th or 14th chromosome [1, 8, 11, 14].

  Symptomatic RLS appears after 50 years, and its causes can be various types of anemia (iron deficiency, B ₁₂ – and folic acid deficiency), renal failure, condition after gastric resection, hypothyroidism and thyrotoxicosis, rheumatoid arthritis, pregnancy.

  Very often, the causes of symptomatic RLS can be polyneuropathy of alcoholic, diabetic, porphyrian etiology, as well as polyneuropathy associated with rheumatoid arthritis, Sjögren’s syndrome. There are indications of the occurrence of RLS in spinal cord tumors, multiple sclerosis, and discogenic radiculopathy [2].

  Pathogenesis of RLS

  Despite the presence of a large number of studies regarding RLS, the pathogenesis of this suffering is not fully understood. Most researchers [1, 2, 8, 11, 13, 14] agree that the pathogenesis of RLS is closely related to dopaminergic deficiency and possible impairment of iron metabolism in the extrapyramidal formations of the brain. The significant role of dopaminergic systems in the development of RLS is indicated by an increase in symptoms under the influence of antipsychotics that block dopamine receptors (D ₂ receptors), as well as drugs that block the release of dopamine (reserpine-like drugs). At the same time, high efficiency in the treatment of the syndrome of dopaminergic drugs (levodopa drugs, dopaminergic receptor agonists) has been shown [2, 7, 8, 11, 14, 16, 22]. Many studies have revealed an inverse relationship between the level of ferritin and the severity of RLS [21]. Iron deficiency can secondarily affect the dysfunction of dopaminergic systems. In addition, iron is a cofactor for the enzyme involved in the synthesis of dopamine, and is also part of the protein D ₂ receptor, therefore, deficiency of this trace element can lead to disruption of dopamine production and normal functioning of D ₂ receptors [2, 8]. And the increase in the symptoms of the disease under the influence of drugs that enhance serotonergic transmission may also be associated with a change in dopaminergic transmission, since serotonergic neurons are able to inhibit the release of dopamine. The existing positive effect of narcotic analgesics (codeine, morphine) can also be regarded as the participation of endogenous opiates in the development of RLS. The therapeutic effect in the treatment of RLS with benzodiazepines and valproic acid preparations may indicate the role of GABAergic systems in the pathogenesis of this disease. It is possible that in the generation of periodic movements that are observed during sleep, spinal mechanisms may also take their place [1, 8, 19].

  Thus, the pathogenesis of RLS is associated with the involvement of many systems. The leading role in it is played by dysfunction of the dopaminergic system [23].

  Clinical picture

  The clinical picture of SBS is reduced, as a rule, to unpleasant sensations in the legs that occur at rest and disappear with active movements. Patients describe this as itching, tingling, burning [3, 8]. These paresthesias are usually localized in the calf muscles, but the hips may also be involved, and less often in the arms. Unpleasant sensations can be both in both legs, and partially. They appear at night, reaching a maximum before the patients go to bed. These unpleasant sensations weaken with active movement, which forces patients to get up and walk (“night walkers”) or simply move their legs, rub their legs with their hands, massage them, take hot or cold foot baths. Increased physical activity, aimed at reducing the symptoms of RLS, leads to sleep disturbance. This leads to the fact that on the second day, patients experience irritability, daytime sleepiness, absent-mindedness, general weakness, fatigue, impaired concentration. It is quite clear that against the background of these disorders, patients may develop anxiety and depressive disorders, which are difficult to treat in the future.

  An indicator of the severity of the disease is the frequency of limb movements per hour [16], registered during a polysomnographic study (periodic movement index):

  – light form – 5-20 per hour;

  – moderate form – 20-60 per hour;

  – severe form – over 60 per hour.

  Diagnostics RLS

  An international research group [24] on the diagnosis of RLS established the criteria necessary for making a diagnosis. This takes into account the main diagnostic criteria, auxiliary and associated symptoms (Table 1).

  Thus, the diagnosis is based on the patient’s complaints and the characteristic clinical picture. Particular attention should be paid to collecting a family history, since a detailed history [5] in most patients with primary RLS reveals a positive family history. To exclude symptomatic (secondary) forms of RLS, a complete neurological and somatic clinical examination, including laboratory screening data, should be performed. Due to the fact that iron deficiency is one of the most common causes of symptomatic forms of RLS, it is useful to determine the level of ferritin in the blood serum (normal > 50 µg/l). If kidney disease is suspected, a thorough examination of the urine is necessary, as well as the determination of urea and creatinine, in the presence of diabetes, the determination of glucose in the blood and urine, as well as acetone.

  Electroneuromyography (ENMG) is indicated for the diagnosis of other symptomatic forms of symptomatic polyneuropathy. Polysomnography with sleep quality assessment is used mainly for research and evaluation of the results of ongoing treatment, and is not at all necessary for the routine diagnosis of RLS.

  Differential diagnosis

  It has been established that RLS can cause or exacerbate any antidopaminergic drugs and a number of other drugs. Below we list the leading drugs that increase RLS, namely nicotine, caffeine and products containing it, metoproclamide, prochlorperazine, antipsychotics, tricyclic antidepressants, diphenhydrazine, alcohol, lithium preparations, terbutaline, calcium and H 9 antagonists0130 2 – histamine receptors, antihistamines.

  For differential diagnosis, it is necessary to consider such diseases, the clinical picture of which is similar to the manifestations of RLS: peripheral vascular disease – obliterating endarteritis, atherosclerosis of the vessels of the lower extremities, thrombophlebitis. Paresthesia, pain in diseases of the lower extremities, as a rule, increase with movement, physical activity and decrease at rest.

  A visual and objective examination of the extremities also helps in the differential diagnosis of these diseases: for the presence or weakening and absence of a pulse; the presence of ulcers is also an important diagnostic feature.

  Peripheral polyneuropathies of any origin, and in particular those associated with vitamin B deficiency ₁₂ , can cause paresthesias that are usually observed throughout the day and are not timed to night or evening. At the same time, there is no desire to imitatively move the legs, do physical exercises for the legs with a feeling of relief after such movements [10].

  Akathisia
  (patient’s restlessness with a constant desire to move)

  Symptom complex associated with long-term use and overdose of antipsychotics. In this condition, patients are forced to move in order to relieve a sense of internal tension. There is restlessness, the inability to stay in one place. This state continues throughout the day. At the same time, with RLS, movements in general and in particular with the legs can reduce paresthesias and symptoms of RLS, which increase in the evening and at night. In patients with akathisia, there is no family history and sleep is disturbed to a lesser extent, there is information about taking antipsychotics.

  RLS must also be differentiated from hypnic myoclonus, short-term generalized twitches that occur at the time of falling asleep. This may be a variant of physiological myoclonus. They may be accompanied by a sinking sensation, but not discomfort in the lower extremities.

  Differential diagnosis with diseases that cause secondary forms of RLS is carried out according to the general principles of verification of these diseases.

  RLS is sometimes detected in patients with Parkinson’s disease, essential tremor, Tourette’s syndrome, Huntington’s disease, amyotrophic lateral sclerosis, postmyelitic syndrome, but it remains unclear whether this combination is due to a coincidence (due to the high prevalence of RLS), the presence of common pathogenetic mechanisms or the use medicines [7, 19].

  A positive response of patients to dopamine-stimulating therapy is currently considered to be a powerful additional differential criterion. In fact, the establishment of the role of disruption of dopamine mediation in the brain in the pathophysiology of RLS was perhaps the main reason for distinguishing it as an independent neurological disorder.

  Another feature of the clinical manifestations in patients with RLS is the circadian rhythm of increased intensity of sensory symptoms in the evening and at night (peak occurs between midnight and 4 am). Conversely, the minimum intensity is associated with the late morning hours (around 10 am). It is interesting to note that these symptoms follow the circadian pattern of body temperature: with maximum intensity during the falling phase of the temperature curve and minimization with an increase in the level of daily body temperature [11].

  Treatment of RLS

  Therapeutic tactics of RLS depends on the cause of the disease (primary or secondary syndrome) and the severity of clinical manifestations. All types of treatment can be divided into non-drug and drug, but sometimes they have to be used in combination. The best non-drug treatment is a variety of activities that can alleviate the symptoms of the disease as much as possible. Some help is provided by physical exercises, sometimes ordinary foot movements, intense rubbing of the legs, very hot or cold foot baths, intellectual activity that requires significant attention (video games, drawing, discussions, computer programming, etc.). The use of various physiotherapeutic procedures is shown – magnetotherapy, lymphopress, massage, mud, etc. However, their effectiveness is purely individual.

  A feature of RLS drug therapy is the method of drug titration:

  – start with the lowest effective doses of drugs;

  – increase the dosage gradually until the desired effect is achieved;

  – often requires sequential testing of several drugs in order to select the most effective;

  – a combination of drugs with different mechanisms of action can give a better effect than monotherapy.

  Below we present the different groups of drugs used in patients with RLS.

  Sleeping pills and tranquilizers

  The effectiveness of clonazepam at a dose of 0.5 to 4.0 mg, restoril (temazepam) at a dose of 15–30 mg, chalcyone (triazolam) at a dose of 0.125–0.5 mg, and ambien (zolpidem) at a dose of 10–20 mg / day has been shown. day. Long-term treatment with these drugs carries the risk of addiction and may cause unwanted daytime sedation [2, 4, 14, 16].

  In this regard, at present, in mild or moderate cases, benzodiazepines are used occasionally – during the period of deterioration, and in severe cases they are prescribed only when dopaminergic agents are ineffective [20].

  Historically, the Turkish physician Sevket Akpinar described in 1982 the first case of the excellent effect of levodopa in a patient with RLS [11]. Dopaminergic drugs quickly contribute to the regression of RLS manifestations. Sinemet is the most effective in this group. It is a combination of carbidopa and levodopa. Even very small doses of sinemet (1/2 or 1 tab. 25/100 mg) can almost completely eliminate symptoms. Dopaminergic therapy leads to improvement in more than 90% of patients. The negative point of levodopa preparations is a possible increase in symptoms in the second half of the night and in the morning – a rebound symptom [8, 13, 22]. Due to the short duration of action of Sinemet 25/100, it is sometimes necessary to take the drug in the second half of the night. To avoid this, you can use a drug with a gradual release of the active substance (sinemet SR). A remarkable property of this drug is the ability to use it during the day to relieve the symptoms of RLS that occur in a sedentary state, for example, during long flights or trips, in a car, rail transport.

  The main problem associated with long-term use of sinemet is the possible increase in the clinical manifestations of RLS. This phenomenon is called the amplification effect or the recoil phenomenon [14]. In order to prevent this complication, it is recommended to take no more than 2-3 tablets. sinemet 25/100 mg daily.

  Another long-acting levodopa drug is madopar (levodopa + benseroside). Its positive effect was noted not only in relation to the quality of sleep and the reduction of periodic leg movements, but also paresthesia [22]. The high efficiency of pergolide (Permax) has also been shown. The usual dosage of this drug is 0.1 to 0.6 mg. The dose should be carefully increased starting from 0.05 mg per day. This drug is a dopamine receptor agonist. There is evidence of the effectiveness of Parlodel (Bromocriptine). Usual dosages range from 5 to 15 mg per day [11].

  There is evidence of the possibility of using well-established drugs for parkinsonism in RLS, for example mirapex (pramipexole). But rather high cost does not allow to use it widely [16].

  Anticonvulsants

  Carbamazepine (finlepsin), tegretol, finlepsin 400 retard have been used for a long time. Finlepsin 400 retard can be used in 1-2 tables. in a day. But the most promising drug from this group is gabapentin (Neurotin), which is used at a dose of up to 2700 mg per day. It is especially effective in the treatment of mild to moderate forms of RLS, in which pain is noted [16].

  Opiates

  This group of drugs is used in especially severe cases. May be used codeine 15 to 240 mg/day, propoxyphene 130 to 520 mg/day, oxycodone 2.5 to 20 mg/day, pentazocine 50 to 200 mg/day, methadone 5 to 50 mg/day, tramadol 50 to 100 mg/day. The disadvantages of these drugs are the development of moderate tolerance and the difficulty in prescribing these drugs, which are strictly controlled by a doctor [16].

  Other drugs

  In some observations, the effectiveness of beta-blockers, serotonin precursors, non-narcotic analgesics, vasodilators, antidepressants was shown. However, these drugs can in some cases exacerbate RLS symptoms, so their use is considered when all other treatments have failed or were poorly tolerated [11, 14, 16].

  The treatment of secondary RLS is the therapy of deficient conditions. It has been established that iron deficiency (a decrease in the level of ferritin less than 40 µg/l) can be the cause of secondary RLS, and at the same time, the lack of this microelement may not be accompanied by clinically pronounced anemia. In these cases, it is possible to recommend taking ferrous sulfate tablets 325 mg 3 times a day. Folic acid and vitamin B 9 deficiency0130 12 requires appropriate self-treatment [10].

  If RLS occurs against the background of renal failure, the arsenal of therapeutic agents can include the elimination of anemia by prescribing erythropoietin, clonidine, dopaminergic drugs and opiates, as well as hemodialysis. In some patients with idiopathic RLS, vitamin E, magnesium preparations, and amantadine may be effective [8].

  Terminals

  The modern arsenal of pharmacological agents available to doctors in most cases makes it possible to achieve almost complete elimination of symptoms and a significant improvement in the quality of life in the vast majority of patients with RLS.