Restless legs – (RLS) -A higher risk for cardiovascular events in women: By Dr. De Leon

Happy 2018 to all my friends and followers- hope everyone is staying healthy and keeping a positive outlook for the new year.

This year I would like for you to join me in actively pursuing a lifestyle which will help us live better, happier, and healthier. This begins by recognizing what problems we have and actively finding solutions. For instance, my biggest challenge this year will be to mange my sleep deprivation better (more on this soon) trying new treatments to get my sleep wake cycle into a more normal state.

Now that I am almost done getting the house back in order after the holidays, I thought it was time to address a common problem found in nearly 50% of PD patients; as well as other parkinsonian syndromes such as MSA known as restless leg syndrome (RLS). This is a nervous system disorder that causes an urge to move the legs (arms, or other body parts) usually one limb at a time. This an extremely uncomfortable sensation in which only way to temporarily relief the urge is to move the limb or walk. These feelings are described as having ‘pins and needles‘  ‘creepy crawly sensation‘ as well as an ‘itching sensation‘ which occurs mostly at rest sitting or lying down. Because it occurs frequently at night it causes severe disruption of sleep – believe me it is nearly impossible to fall asleep when legs feel like they wont stand still although no involuntary movements present just an intense sensation of discomfort and need to move and walk about; hence it is also classified as a sleep disorder.

I have mentioned in the past that RLS is not only a symptom of the disease but can be a n initial problem even years before other motor symptoms developed. Plus, it also is a risk factor for developing PD. We may recall that RLS can be a familial disease and a secondary problem such as in PD but also as part of  iron deficiency, neuropathy, diabetes, kidney failure, and pregnancy (extremely frequent in third trimester). when i experience these symptoms is because my neupro patch has fallen off or i re-injured my back and is causing me radiculopathy- both of which i treat immediately.

But, until recently we were not aware that having RLS was a contributor of  cardiovascular events at a greater rate in women compared to men according to a robust study of  nearly 58,000 women from Nurse’s Heath study.

Rls affects about 10% of the population. but is more commonly seen in women than men. Perhaps this fact is skewing results and causing disparity in mortality rates. Nevertheless, we cannot ignore these new findings because as you know, I along with many others have been discussing for a while now the fact that there are great differences in PD presentation according to gender. I have also said that women are at higher risk for strokes and heart attacks from PD. Now we have another factor commonly seen in many PD patients which if not properly treated can accelerate the risk to death from one of these events. Although further research is needed into this area. it could be that not just women with RLS may be at higher risk  for strokes and heart attacks but more importantly those of us women with PD may also be at a much higher risk.

The theory behind the cause for this disparity is attributed to the autonomic and dopamine dysfunction particularly sympathetic stimulation which raises blood pressure.

In order to decrease risk of cardiovascular events, first we must diagnose and treat the problem.

RLS is diagnosed clinically.

Triggers for RLS:

certain medications can worsen symptoms

• anti-nausea medications like phenergan, compazine ( same one that will worsen PD symptoms
• cold and allergy medicines – dextrometomorphan
• alcohol
• sleep deprivation
• withdrawal from neupro patch
• caffeine

RLS treatments:

• According to recent AAN Guidelines for treatment of RLS- first treatment should include mirapex ( in my professional experience as well as per guidelines this works much better than requip), Neupro patch (rotigotine) and Horizant (gabapentin enacarbil).
• DBS may be the next thing in treating RLS; so far in a small study of 22 patients researchers have shown sustained relief /improvement of symptoms 2 years after surgery.
• 24 hour infusion of duopa also has been shown to relieve symptoms

However, we still have to be cautious about new treatments on the horizon and over the counter/home remedies as a significant reliable treatment because there appears to be a greater than usual placebo effect. 48 out of 68 studied patients with rls showed marked improvement in sleep and quality of life on placebo although the daytime sleepiness  worsened.

So the moral of the story, there appears to be increase risk of mortality in women with RLS which may translate to the same risk or even higher in women with PD. Hence important to be treated – best by adjusting PD medicines in my experience and ruling out secondary causes if symptoms worsen or persist. Ok to try massages and other alternative treatments like leg pumps, soap bars in socks or mattress but if sleepiness is not improved than sure sign that root of problem is not being targeted and can still lead to increase mortality. Any questions concerns especially if already have history of risk factors for stroke like obesity, high blood pressure, diabetes, or smoking need to discuss treatment plan with PCP/neurologists asap.

lets us all do our best to be proactive in our health this year!

copyright @2018

all rights reserved by Maria De Leon MD

Sources:

http://www.medscape.com/viewarticle/890643 (women at higher risk of cv)

http://www.medscape.com/viewarticle/872681 (aan guidelines)

http://www.medscape.com/viewarticle/847146 (Dbs surgery)

http://www.medscape.com/viewarticle/865307 (dopa infusion)

http://www.medscape.com/viewarticle/865627 (placebo effect)