From the Guidelines
For treating restless legs syndrome (RLS) in a patient with chronic lymphocytic leukemia (CLL), I recommend starting with non-pharmacological approaches and considering ferrous sulfate supplementation if iron deficiency is present, as suggested by the American Academy of Sleep Medicine 1.
Treatment Options
When considering pharmacological treatment, the following options can be taken into account:
- Dopamine agonists like pramipexole or ropinirole, although the AASM suggests against their standard use in adults with RLS 1
- Alpha-2-delta calcium channel ligands like gabapentin, which may be considered for patients with RLS and end-stage renal disease (ESRD) 1
- Opioids like extended-release oxycodone, which may be used in adults with RLS, although with caution due to addiction potential 1
Important Considerations
- Check for iron deficiency, as it can worsen RLS, and supplement with iron if ferritin is below 75 ng/mL
- Be cautious with dopaminergic medications, as they can cause augmentation (worsening of symptoms) with long-term use
- Regular monitoring is essential, as CLL progression or treatments may affect RLS symptoms or medication metabolism
CLL-Specific Considerations
- The treatment of CLL itself, as outlined in the ESMO clinical practice guidelines 1, may impact the management of RLS
- Patients with CLL should be treated with caution, taking into account their overall health status, comorbidities, and potential interactions between CLL treatments and RLS medications
From the FDA Drug Label
The effectiveness of ropinirole in the treatment of RLS was demonstrated in randomized, double-blind, placebo-controlled trials in adults diagnosed with RLS using the International Restless Legs Syndrome Study Group diagnostic criteria Patients were required to have a history of a minimum of 15 RLS episodes/month during the previous month and a total score of ≥15 on the International RLS Rating Scale (IRLS scale) at baseline. Patients with RLS secondary to other conditions (e.g., pregnancy, renal failure, anemia) were excluded.
The treatment options for restless legs syndrome in a patient with Chronic Lymphocytic Leukemia (CLL) are not directly addressed in the provided drug labels.
- Key consideration: The labels do mention that patients with RLS secondary to other conditions, such as anemia, were excluded from the trials.
- Clinical decision: Given the lack of direct information, it is unclear if ropinirole is safe and effective for patients with CLL. 2 2
From the Research
Treatment Options for Restless Legs Syndrome
The treatment options for restless legs syndrome (RLS) can be categorized into nonpharmacologic and pharmacologic therapies 3.
- Nonpharmacologic Therapy: This includes good sleep hygiene and avoidance of medications and factors that provoke symptoms 3.
- Pharmacologic Therapy:
- First-line Treatment: Dopaminergic agonists (pramipexole, ropinirole, rotigotine) are considered the first-line treatment for moderate to severe RLS 4, 5, 6.
- Alternative Treatments: Antiepileptic (gabapentin, pregabalin) or opioid (oxycodone, tramadol) drugs can be used in severe, refractory, or neuropathy-associated RLS 4, 5.
- Lesser-known Treatments: Clonidine, adenosic agents, glutamate AMPA receptor blocking agents, glutamate NMDA receptor blocking agents, various anticonvulsants, anti-inflammatory agents, and cannabis may also be considered 7.
- Treatment for Co-existent Depression: Bupropion can be used to treat co-existent depression in RLS due to its pro-dopaminergic properties 7.
Considerations for Patients with Chronic Lymphocytic Leukemia (CLL)
While there is no specific evidence on the treatment of RLS in patients with CLL, the general treatment options for RLS can be applied. However, it is essential to consider the potential interactions between RLS treatments and CLL medications, as well as the patient's overall health status.
- Iron Deficiency: Iron deficiency must be identified and treated, as it may improve RLS symptoms and potentially lower the risk of augmentation 5.
- Augmentation: The phenomenon of RLS augmentation, a paradoxical worsening of symptoms by dopaminergic treatment, remains a major problem in the treatment of RLS, and prevention of augmentation is one of the main goals in the management of RLS 5.