Is oxycodone (OxyContin) recommended for Restless Legs Syndrome (RLS)?

Oxycodone for Restless Legs Syndrome (RLS)

Extended-release oxycodone and other opioids are recommended for adults with RLS as a second-line treatment option when first-line therapies fail, particularly for severe to very severe cases. 1

Treatment Algorithm for RLS

First-line Treatments (Try these before oxycodone)

1. Alpha-2-delta ligands

   • Gabapentin enacarbil (strong recommendation, moderate evidence) 1
   • Gabapentin (strong recommendation, moderate evidence) 1
   • Pregabalin (strong recommendation, moderate evidence) 1

2. Iron therapy (for patients with appropriate iron status)

   • IV ferric carboxymaltose (strong recommendation, moderate evidence) 1
   • Oral ferrous sulfate (conditional recommendation, moderate evidence) 1

Second-line Treatments

1. Opioids

   • Extended-release oxycodone and other opioids (conditional recommendation, moderate evidence) 1
   • Specifically, oxycodone-naloxone prolonged-release has been approved in Europe for severe to very severe RLS after failure of dopaminergic therapy 2, 3

2. Other options

   • Dipyridamole (conditional recommendation, low evidence) 1
   • Bilateral high-frequency peroneal nerve stimulation (conditional recommendation, moderate evidence) 1

Clinical Considerations for Oxycodone Use in RLS

When to Consider Oxycodone

• For patients with severe RLS inadequately controlled by first-line treatments 4
• For RLS symptoms present throughout much of the day and night 5
• For refractory cases where alpha-2-delta ligands and other treatments have failed 2

Benefits of Oxycodone in RLS

• Provides significant and sustained improvement in RLS symptoms 2
• Improves disease-specific quality of life and sleep 3
• Does not appear to cause augmentation (worsening of symptoms), which is a common complication with dopaminergic agents 3

Potential Adverse Effects

• Fatigue, constipation, nausea, headache
• Hyperhidrosis, somnolence, dry mouth, pruritus 2
• Risk of opioid-related complications (dependence, tolerance)

Important Caveats

• The oxycodone-naloxone combination may be preferable as it counteracts opioid-induced bowel dysfunction 3
• Long-term comparative studies between opioids and other RLS medications are still needed 4, 2
• Monitor for typical opioid-related side effects and dependence
• Consider the risk-benefit ratio carefully, especially given the potential for opioid misuse
• Dosing should start low and be titrated based on symptom control and side effects

Treatments Not Recommended for RLS

The AASM specifically recommends against several medications for RLS, including:

• Dopamine agonists like pramipexole, ropinirole, and rotigotine (due to risk of augmentation) 1
• Bupropion, carbamazepine, clonazepam, valproic acid 1
• Cabergoline (strong recommendation against) 1

While oxycodone is not a first-line treatment for RLS, it has a legitimate role in the management of severe cases that have failed to respond to preferred therapies, with evidence supporting its efficacy and safety in this specific context.