Rotational Medication Regime

[ircam2112]

I’m wondering if anyone has tried a rotational medication regime (i.e. Tramadol for 1 week, Requip for 10 days, Gabapentin for 7 days - rinse and repeat) and what thier experiences were like?

[SueJohnson]

You need to get off the requip. Up to 70% of people on it will eventually suffer from augmentation and believe me you don't want that. Reduce by 25 mg every 2 weeks or so. You will suffer and this is where the tramadol will come in. The gabapentin won't fully work until you are off requip but take it at the same time you are on requip. Requip used to be the first-line treatment which is why so many doctors prescribed it but they are not up to date on the current treatment recommendations. Check out the Mayo Clinic Updated Algorithm on RLS which will tell you everything you want to know including about its treatment and refer your doctor to it if needed as many doctors do not know much about RLS or are not uptodate on it as yours obviously isn't at

Https://mayoclinicproceedings.org/a... Also have you had your ferritin checked? If it is below 100 improving it to 100 or more helps 60% of patients and in some will completely eliminate their symptoms. If you haven't had your ferritin checked, ask your doctor for a full iron panel. Stop taking any iron supplements 48 hours before the test and fast after midnight. Have your test in the morning when your ferritin is lowest. When you get the results, ask for your ferritin and transferrin saturation numbers. You want your ferritin to be over 100. If your ferritin is less than 75 then take 325 mg of ferrous sulfate with 100 mg of vitamin C or some orange juice since that helps its absorption. Take it every other day at least 1 hour before a meal or coffee and at least 2 hours after a meal or coffee since iron is absorbed better on an empty stomach. If you have problems with constipation switch to iron bisglycinate. If your ferritin is between 75 and 100 or if your transferrin saturation is below 20, you probably need an iron infusion since iron isn't absorbed as well above 75. If you take magnesium take it at least 2 hours apart since it interferes with the absorption of iron. It takes several months for the iron tablets or iron infusion to slowly raise your ferritin. Ask for a new blood test after 8 weeks if you have an iron infusion or after 3 months if you are taking iron tablets. How much gabapentin are you taking? After you are off requip for several weeks increase it by 100 mg every couple of days until you find the dose that works for you. Take it 1-2 hours before bedtime. If you need more than 600 mg take the extra 4 hours before bedtime as it is not as well absorbed above 600 mg. If you need more than 1200 mg, take the extra 6 hours before bedtime. Most of the side effects of gabapentin will disappear after a few weeks and the few that don't will usually lessen. Those that remain are usually worth it for the elimination of the RLS symptoms. According to the Mayo Clinic Updated Algorithm on RLS: "Most RLS patients require 1200 to 1800 mg of gabapentin daily." If you take magnesium don't take it within 3 hours of taking gabapentin as it will interfere with the absorption of the gabapentin. After finding the dose that works for you, you may find you no longer need the tramadol. Good luck.

[Madlegs1 in reply to SueJohnson]

But-- would the rotation idea work?😉🥵😎

[SueJohnson in reply to Madlegs1]

This is just my guess. Probably OK while on tramadol and requip, but probably not while on gabapentin alone.

[LanaCSR in reply to Madlegs1]

Absolutely the rotation will work. I have heard it helps many to avoid augmentation and still get relief from RLS. Even a doctor I have seen for RLS recommends a rotation of meds. It doesn't have to necessarily be those listed above, but it should be the ones that work best for you. Good luck!!

[ircam2112 in reply to SueJohnson]

I should have been more specific. That was just an example of a rotational schedule. I wouldn’t try a DA for the reasons you state. Mine will likely include Pregabalin, an opiate, Clonazepam and gabapentin each for around 7-10 days. They have all been very effective when I first started each of them but I have likely developed tolerance to them all (been on them for at least 2 years) and don’t want to continue to go up and up on the dosage to get the same effect. Our hope is that the rotational schedule will eliminate both tolerance and dependency while maximizing effectiveness. I’m excited about it but it’s been tough getting there so far - symptoms getting worse and worse though am tapering slowly.

At my request, to maybe help me get through this transition period, I had my Iron Deficiency Panel done today and meet with my doctor tomorrow to determine if he’ll recommend an IV Iron Infusion. Thanks for the response Sue. Good, timely information.

[SueJohnson in reply to ircam2112]

Clonazepam helps with sleep but not with RLS symptoms per se, so while off it, you will likely have increased symptoms. Since pregabalin and gabapentin are basically the same thing, I don't see much sense in including both in your rotation. If you are on a high enough dose of gabapentin or pregabalin that you don't want to increase it , one should decrease it slowly to avoid withdrawal effects not stop it suddenly and switch to tramadol.

[LanaCSR in reply to SueJohnson]

The rotation of meds should be done under a doctor's advice. This disclaimer should be added whenever you respond to others on here. Everybody is different and not everything will work for everybody. Not to mention only the person's doctor who is treating them should be advising them on all of these other things. We want to keep everyone safe in here.

[ircam2112 in reply to LanaCSR]

Yes, agree. I’m working closely with a Movement Disorder neurologist.

[ircam2112 in reply to SueJohnson]

Thanks for the input but my experience with Clonazepam is different. It definitely helps with sleep but also significantly decreases PLMD per video taping sleep and EDS. Prior to starting Clonazepam and, without other medications on board, I had symptoms all day. Within 2-3 days my daytime symptoms disappeared and nighttime PLMS decreased significantly. Also, when I’ve lowered Clonazepam in the past, nighttime PLMS increased within a few days and daytime symptoms returned within a few weeks. While the medical community gives a low evidence of effectiveness, my experience indicates it directly impacts symptoms. We are often ahead of the medical community when it comes to knowing what works and what doesn’t and often it’s just because there have been too few clinical studies to support recommending a particular medication.

Clonazepam has been the “workhorse” medication for my symptom control and, as long as someone knows the risks of Clonazepam (tolerance, dependence and withdrawal symptoms) and there are few or no other alternatives, I would strongly recommend trying it.

Pregabalin and Gabapentin are similar (analogs), but not the same as they differ in structure. Pregabalin is: (S)-β-isobutyl-GABA and Gabapentin is: 1-(aminomethyl)cyclohexane acetic acid. As such they differ in their affinities to various receptor sites.

[SueJohnson in reply to ircam2112]

That is very interesting. I have made a note of it.

[LanaCSR in reply to ircam2112]

See my reply above about the rotation regime. As you mentioned, it seems that most of the meds we all use/try for RLS seem to start out working well at first and then begin losing their effectiveness. This is why a rotation works so well. Good luck and let us know how it turns out!

[ircam2112 in reply to LanaCSR]

Thanks. Will let you know. I’ve discontinued Pregabalin and am close to discontinuing Gabapentin. Clonazepam is next and will be a long, possibly very difficult process as I’ve done it twice in the past.

[Munroist]

A number of people have posted in the past that they either rotate medications or take regular holidays from them and that this seems to maintain the benefits and removes the need for gradually increasing doses. I don’t currently take medication for RLS but I suspect changing every week would be much too quick and you wouldn’t see the proper benefits of any of the drugs. Suejohnsons advice above is the best standard approach. There are suspicions that dopamine agonists can have permanent effects especially on the doses which lead to augmentation so it’s worth considering whether you want to ever take them.

[LanaCSR in reply to Munroist]

I agree you don't want to rotate too quickly, but definitely rotation of meds works on a longer term basis.

[ircam2112 in reply to LanaCSR]

The reason for the quick rotation is to avoid physical dependence which can occur rapidly esp. with opioids and benzodiazepines. It’ll be a work in progress until we have a schedule dialed in.

[ircam2112 in reply to Munroist]

My experience has been that the medications I listed as being the potential ones for rotation, have been effective the first night I used them possibly with the exception of gabapentin. Complicating things though, is that except for Clonazepam, I was also on other medications when I began the others. E.g.) I was taking Clonazepam and Gabapentin when I started Pregabalin, which improved symptoms the first night.

The reason for the quick rotation is to avoid physical dependence which can occur rapidly esp. with opioids and benzodiazepines. It’ll be a work in progress until we have a schedule dialed in.