Drug Treatment

No drugs are currently licensed for treatment of RLS in the UK or USA. However, a large number of drugs have been used after clinical trials in RLS. In particular, dopamine agonists have been shown to be effective based on placebo controlled randomised trials. The drugs used in RLS generally belong to the following classes:

1. Start treatment with a dopamine agonist (all newer agonists such as pergolide, cabergoline, pramipexole and ropinirole are effective and should be given as a single dose in the evening).
2. If patients are intolerant to dopamine agonists then levodopa (Sinemet or Madopar) should be given at night-time before bed. 80-82% of paitents taking levodopa may develop augmentation or rebound.
3. If levodopa is no longer effective or if symptoms start appearing in the early morning (rebound phenomenon) or evening/daytime with spread to upper limb (augmentation), then dopamine agonists may be reintroduced. At this stage cabergoline may be particularly useful as this drug works given once daily. Dopamine agonists with shorter half-life may need to be given up to 3 times a day.
4. If symptoms are resistant then an antiepileptic drug such as carbamazepine or gabapentin may be tried. These drugs inhibit the hyperactivity of the nervous system that may be related to the symptoms. Gabapentin may be particularly useful for haemodialysis patients because it is dialyzable and has a long half-life, and for 'painful' RLS.
5. Severe unremitting painful RLS may need to be treated by strong painkillers such as Codeine, Tramadol, Oxycodone or Propoxyphene under specialist guidance
6. Bedtime sedatives such as clonazepam or zopiclone may be useful in some cases with severe insomnia. These may also exert a beneficial effect by reducing nervous activity and by increasing muscle relaxation.
7. In some severe cases unresponsive to above, patients may need hospitalisation and treatment with subcutaneous apomorphine given overnight by a pump in specialist centres.