Christopher J. Earley, MB, BCh, PhD Professor Department of Neurology Johns Hopkins School of Medicine

Transcription

1 Christopher J. Earley, MB, BCh, PhD Professor Department of Neurology Johns Hopkins School of Medicine

2 1. Medication working well but do you still need it? 2. Medication working well but do you really want to be on it? 3. You are having problems with the current medication

3 1. Family history study indicates significant symptom variability over time 2. Potential triggers or aggravants may be reduced or eliminated Iron deficiency (6 weeks) Poor sleep (e.g., sleep apnea) Pain conditions (e.g., knee replacement) Medications (e.g., antidepressants) Pregnancy

4 1. RLS x 22 years 2. Gabapentin; no SX on TX 3. Current dose 1800mg at night 4. Ferritin 117 ug/l 5. Unable to refill RX on time 6. 6 days drug free occasional, minimal SX ; hydrocodone prn

5 1. RLS x 12 years 2. Requip then Mirapex (0.75 mg) 3. RLS throughout day; hypersomnia 4. Ferritin 154 ug/l 5. Venlafaxin 150 mg x 12 years 6. Off Mirapex 11 day nightly RLS 7. Off Venlafaxin 5 days no SX

6 1. RLS x 6 years; blood donor/nsaid 2. Pramipexole (0.5 mg) 6 year 3. Ferritin 35 ug/l mg (IV) iron 5. 6-weeks post iron infusion then tapered off pramipexole days drug free no SX

7 This is not about need as you may still have RLS when you get off the drug. The question is, do I want to be on this drug every day for the rest of my life?

8 1. RLS x 55 years 2. Bedside bicycle for 40 years 3. Enticed by advertising; Mirapex 0.5 mg x 8 year 4. Medication working alright but did not want to take medication anymore 5. Tapered off days drug free baseline: nightly bedtime RLS. Return to bedside bicycle

9 The usual problems are : 1. Side effects 2. Tolerance (opiates and Alpha-2 delta) 3. Augmentation (Dopamine agents) 4. Occasionally, financial

10 1. RLS x 15 years 2. Methadone 10 mg x 5 year 3. C/O daytime sleepiness 4. Ferritin 110 ug/l 5. Tapered off days drug free evening RLS, so returned to methadone 7.5 mg BUT now no sleepiness

11 1. RLS x 30 years 2. DA agonist for 15 yrs; direct conversion to oxycodone ER 3. Currently oxycodone ER 40 mg TID 4. Ferritin 210 ug/l 5. Tapered off oxycodone days drug free restarted oxycodone ER 10mg PM and 20 mg qhs

12 1. RLS x 37 years 2. Requip for 12 year; augmented 3. Current dose 4 mg 4. Ferritin Tapered off days drug free mild, bedtime SX 4/7 nights - no further meds

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14 1. Down regulation of DA receptor 2. Imbalance in the DA receptor Type D1-D 2 Pre vs post D2/3/5 or D1/5 3. Alterations of DAR interaction 4. Feedback inhibition of dopamine synthesis

15 Normal Conditions Decreasing DA Activity (augmentation and tolerance) RLS Pre-treatment Symptomatic period RLS Post-treatment Diurnal Changes in Dopaminergic Activity Earlier onset RLS Symptom Threshold NIGHT DAY

16 Is a result of chronic use of dopamine drugs Which results in decrease in the brain s natural dopamine levels AND A increase in dependency on the dopamine drug

17 Reducing DA drug Þ insufficient brain DA Þ increased production of DA Reducing DA drug Þ insufficient brain DA Þ rebound of RLS Increased DA production Þ improvement in RLS

18 Start with earliest scheduled dose Incremental Reduction 0.25 mg Pramipexole 0.5 mg ropinirole 1 mg rotigotine Rate of reduction Every 3-5 days minimum

19 From tapering to drug free Days 1-2: RLS severe; NO sleep Days 3-4: RLS severe, 1-2 Hrs total sleep; sleepiness, depression, anxiety Days 5-7: 2-4 hrs sleep; symptoms continue to role back; less intense Days 10-14: 4-6 hrs sleep; evening bedtime Sx; baseline?

20 Symptoms may continue to improve 3-6 months Living drug-free with RLS is a personal decision Once augmented; always augmented Return to prior drug if not DA agent Try an alternative treatment

21 Available to Foundation Members at

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