What muscle relaxers are recommended for severe restless leg syndrome?

Muscle Relaxers for Severe Restless Leg Syndrome

Alpha-2-delta ligands (gabapentin, pregabalin, or gabapentin enacarbil) are strongly recommended as first-line treatment for severe restless legs syndrome, not traditional muscle relaxants. 1, 2

First-Line Treatment Options

• Alpha-2-delta ligands are the preferred first-line pharmacological treatment for RLS due to their efficacy and lower risk of augmentation compared to dopaminergic agents 1, 2, 3
• Specific recommended medications include:
  • Gabapentin: Start with low doses and titrate as needed 1, 2
  • Pregabalin: Effective alternative with similar mechanism 1, 2
  • Gabapentin enacarbil: Extended-release formulation with improved bioavailability 1, 2

Iron Therapy Considerations

• Check serum iron studies, including ferritin and transferrin saturation, in all patients with RLS 1, 2
• Consider iron supplementation if ferritin ≤75 ng/mL or transferrin saturation <20% 1, 2
• Options include:
  • Oral ferrous sulfate (conditional recommendation with moderate certainty) 1
  • IV ferric carboxymaltose for patients who don't respond to oral therapy (strong recommendation with moderate certainty) 1

Second-Line Treatment Options

• Extended-release oxycodone and other opioids are conditionally recommended for refractory cases or when treating augmentation from dopaminergic agents 1, 4
• Opioids have shown effectiveness for relieving symptoms in severe cases, with studies showing relatively low risks of abuse in appropriately screened patients 1, 4

Medications to Avoid or Use with Caution

• Traditional muscle relaxants are not specifically recommended in guidelines for RLS treatment 1, 2
• Dopaminergic agents (levodopa, pramipexole, ropinirole, rotigotine) should be avoided as standard treatment due to high risk of augmentation - a paradoxical worsening of symptoms with long-term use 1, 3
• The American Academy of Sleep Medicine specifically recommends against:
  • Bupropion, carbamazepine, clonazepam, and valproic acid 1
  • Benzodiazepines in elderly patients as they can cause decreased cognitive performance 2

Non-Pharmacological Approaches

• Bilateral high-frequency peroneal nerve stimulation is conditionally recommended as a non-pharmacological option 1, 5
• Implement moderate exercise, smoking cessation, alcohol avoidance, and caffeine reduction 2, 5
• Address any underlying conditions or medications that may exacerbate RLS symptoms 1, 2

Managing Treatment Complications

• Monitor for side effects of alpha-2-delta ligands, including dizziness and somnolence 1
• If using dopaminergic agents, watch for augmentation, characterized by earlier onset of symptoms, increased intensity, and spread to other body parts 1, 2, 4
• If augmentation occurs, consider taking medication doses earlier in the day, splitting existing doses, or switching to an alpha-2-delta ligand or opioid 2, 4

Special Considerations

• For patients with end-stage renal disease and RLS, gabapentin is conditionally recommended (very low certainty of evidence) 1
• In elderly patients, start with lower doses of medications and titrate slowly to minimize side effects 2
• Be vigilant about potential drug interactions with other medications 2