RLS and Parkinsons

[Graham3196]

A relative has Parkinsons disease. She has had some treatment that has improved her condition in the very short term, she is just two weeks since the treatment. She has been on pramipexole for a long time. Some of the parkinsons symptoms have significantly decreased but she still has RLS all the time

Some questions. Why do Parkinson patients take a much higher dose of pramiprexol than RLS patients?

Is there some reason why they don't augment very quickly?

Both RLS and parkinsons symptoms seem to have a lot in common

My proposition is that she has been benefiting from the pramipexole for parkinsons symptoms but at the same time she has augmented on the pramipexole so some of her symptoms were parkinsons and some of them were augmentation Now her parkinsons symptoms have been relieved in full or part she still has the problem of bad symptoms from augmenting.

I'm suggesting that she has had the two sets of symptoms running side by side until now when the parkinson symptoms have decreased but she is still taking pramipexole so she is left with severe augmentation and its awful symptoms.

If there is any validity to this proposal then the logical next step would be to start weaning her body off the pramipexole very slowly and with the help of gabapentin or opiates if possible.

Does anyone have any experience with this situation that might suggest whether my proposition is valid and an opinion on whether or not getting away from pramipexole would be worth trying. Her body is not in great shape after years of parkinsons so unnecessarily subjecting her to weaning off the pramipexole would be a bad course to follow except that the long term effect of high dose pramipexole may be serious in themselves.

There might be a problem that if she stops the pramipexole can Gabapentin or opiates take over to control the RLS without a bad effect of her parkinsons? This probably requires a judgement call from her specialists.

Thanks for any experience or opinions.

[LotteM]

The RLS part of Parkinson's is difficult. People with Parkinson's do not (or hardly) produce dopamine anymore. In RLS, there is enough dopamine, but some dopamine receptors are greatly reduced. So even with artificial dopamine (levodopa) or dopamine agonists like pramipexole, the underlying problem of RLS remains

I think in RLS the (over)stimulation of the few dopamine receptors (temporarily) eases the problem, but may lead to a further reduction in receptors over time. And thus return of symptoms. I suspect the addition of levodopa or stimulation of receptors by pramipexole in people with Parkinson's rarely leads to overstimulation like in oeople with RLS.

Why do you think she has augmentation? Does she have earlier onset of symptoms or even daytime rls, rls in other body parts?

Does rls.org have info and treatment options on RLS in people with Parkinson's? With co-morbidities, that means multiple diseases, you have to tread carefully and be very mindful that treatment of one disease may negatively affect or interfere with an other disease. Think about depression/antidepressives and RLS.

I hope your friend finds good help.

[SueJohnson]

The signs of augmentation are when you have to keep increasing your dose to get relief, or when your symptoms occur earlier in the day or there is a shorter period of rest or inactivity before symptoms start or when they move to other parts of your body (arms, trunk or face) or when the intensity of your symptoms worsen.

If she meets this criteria then she should come off the pramipexole. Unlike us with RLS alone, she should not take iron as Parkinsons patients have sufficient iron. Yes gabapentin is used to improve the rigidity, bradykinesia, and tremor of parkinsonism. She should ask her doctor about Rasagiline (Azilect). Rasagiline is used for Parkinson's and has been used to treat RLS. It is not a dopamine agonist. pubmed.ncbi.nlm.nih.gov/224... "The hope is that Rasagiline, because it prolongs the effect of existing dopamine, instead of producing more, will not come with adverse side effects," I can't find anything that says you can suffer augmentation from it.

Intense exercise can slow the progression of Parkinson's but will exacerbate her Restless Legs symptoms, however I would think that would be worthwhile since Parkinson's is a more serious disease.

If she is augmenting , then to come off pramipexole she should reduce by .125 mg (.088) every 2 weeks or so. She will have increased symptoms. She may need to reduce more slowly or with a smaller amount. She should wait until the increased symptoms from each reduction has settled before going to the next one. She will suffer and may need a low dose opioid temporarily to help out with the symptoms especially as she nears the end. The beginning dose of gabapentin is usually 300 mg (75 mg pregabalin). She should start it 3 weeks before she is off pramipexole although it won't be fully effective until she is off it for several weeks. After that she should increase it by 100 mg (25 mg pregabalin) every couple of days until she finds the dose that works for her. She should take it 1-2 hours before bedtime. If she needs more than 600 mg she should take the extra 4 hours before bedtime as it is not as well absorbed above 600 mg. If she needs more than 1200 mg, she should take the extra 6 hours before bedtime. (One doesn't need to split the doses with pregabalin) Most of the side effects of gabapentin or pregabalin 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. If she takes magnesium she should take it at least 3 hours before or after taking gabapentin (it is OK with pregabalin) as it will interfere with the absorption of it and if she takes calcium she shouldn't take it within 2 hours. According to the Mayo Clinic Updated Algorithm on RLS: "Most RLS patients require 1200 to 1800 mg of gabapentin (200 to 300 mg pregabalin) daily."

She should check out the Mayo Clinic Updated Algorithm on RLS which will tell her everything she wants to know including about its treatment and refer her doctor to it if needed as many doctors do not know much about RLS or are not uptodate on it at Https://mayoclinicproceedings.org/a...

All of this should be discussed with her doctor.