What is the initial treatment for Periodic Limb Movement Syndrome (PLMS)?

From the Guidelines

The initial treatment for Periodic Limb Movement Syndrome (PLMS) should prioritize addressing underlying conditions, such as iron deficiency, and implementing non-pharmacological approaches, including good sleep hygiene practices, rather than immediately starting dopaminergic medications, which have been downgraded due to concerns about augmentation 1. The American Academy of Sleep Medicine suggests against the standard use of levodopa, pramipexole, transdermal rotigotine, and ropinirole for the treatment of RLS due to the risk of augmentation 1. Instead, treatment should focus on correcting iron deficiency with ferrous sulfate, especially in patients with appropriate iron status, as iron administration is generally recommended for those with evidence of iron deficiency 1. Non-pharmacological approaches, such as regular exercise, avoiding caffeine and alcohol in the evening, and maintaining a consistent sleep schedule, should also be implemented to help regulate muscle movements during sleep. If pharmacological treatment is necessary, alternative medications like gabapentin, pregabalin, or clonazepam may be considered, taking into account symptom severity, comorbidities, and patient preference, with the goal of reducing movements and improving sleep quality 1. It's essential to individualize treatment based on the patient's specific needs and to monitor for potential side effects, such as augmentation, to ensure the best possible outcome for patients with PLMS. Key considerations include:

• Addressing underlying conditions, such as iron deficiency
• Implementing non-pharmacological approaches, including good sleep hygiene practices
• Avoiding dopaminergic medications due to concerns about augmentation
• Considering alternative medications, such as gabapentin or pregabalin, if necessary
• Individualizing treatment based on symptom severity, comorbidities, and patient preference.

From the Research

Initial Treatment for Periodic Limb Movement Syndrome (PLMS)

• The initial treatment for PLMS is often based on the treatment of restless legs syndrome (RLS), as the two disorders are related and share similar symptoms 2, 3, 4.
• Dopaminergic agents, such as levodopa and dopamine agonists (e.g. pramipexole, ropinirole), are considered effective treatment options for PLMS 3, 4, 5, 6.
• However, recent evidence suggests that gabapentinoid agents (e.g. gabapentin enacarbil, pregabalin) may be a safer option as initial treatment, with lower risk of augmentation of symptoms 2.
• Iron supplementation therapy may also be considered as an initial treatment option if iron stores are low 2.
• The choice of treatment should be based on the individual patient's symptoms and medical history, and may involve a combination of medications and lifestyle changes.

Treatment Options

• Dopaminergic agents:
  • Levodopa
  • Dopamine agonists (e.g. pramipexole, ropinirole)
• Gabapentinoid agents:
  • Gabapentin enacarbil
  • Pregabalin
• Iron supplementation therapy:
  • Ferric carboxymaltose
• Other treatment options:
  • Anticonvulsants
  • Opioids
  • Sedative/hypnotics

Considerations

• The treatment of PLMS should be individualized and based on the patient's specific symptoms and medical history 3, 4.
• The choice of treatment should take into account the potential risks and benefits of each medication, as well as the patient's lifestyle and preferences 2, 6.