I'm hoping for some advice because my doctor and the neurologists have been no help. For the past few years I have been taking 50mg tramadol, 300mg Gabapentin and 50mg sertraline. Prior to this I managed to wean off Pramipexole. I haven't increased the dosage of any of my current meds because I had hoped that I could manage with the status quo, but unfortunately it's a rare occasion that I get to sleep at 2am - 4am is the norm now for me and I have to be up at 8am for work. I'm also taking OTC solpadeine max - codeine/paracetamol (3 or 4 a night) which I know is a really bad idea on top of the other drugs but it is the only thing that helps when the discomfort is really bad (but the effects don't usually last long). Apart from the very first time I took the tramadol I got the feeling it didn't work that well and I've read in posts here that it's the only opioid that can cause augmentation. It terrifies me but I'm wondering if it would be a good idea to try and stop the tramadol and ask for 30 mg Codeine tablets from the Dr instead which would be safer? I don't like the idea of increasing the gapapentin but perhaps to increase it slightly would compensate. I apologise for the long post but I'm at my wits end (and aren't we all).
Advice on codeine v tramadol - Restless Legs Syn...
Advice on codeine v tramadol
2 years ago you were on Amitriptyline. Was that prescribed for RLS or depression? Now you're on Setraline. Again, is that for RLS or depression?Both these meds trigger/worsen RLS. If they were prescribed for RLS, stop them now, reducing slowly to avoid any withdrawal symptoms. If they were prescribed for depression, discuss fully with your GP and ask if you can switch to the safe option- trazodone.
Tramadol is the only opioid that causes augmentation, especially when you have been on Pramipexole or Ropinirole.
300mg of gabapentin is too low to cover RLS. The RLSUK website has the list of meds and the doses and how to take them.
In your case, stop tramadol, but maybe replace with 30mg codeine. Ask GP to increase gabapentin to the average dose of 1500- 1800mg taken in 600mg doses at night only, 2 hour's apart.
Also ensure serum ferritin is above 100, preferably 200 by taking iron pills every other night/iv iron infusion. Get full panel fasting bloods.
If stopping sertraline, increasing gabapentin and raising serum ferritin don't improve your RLS, it is then considered refractory and low dose long lasting opioids like Buprenorphine will probably be needed. But try the other steps first.
Hi Jools, I take the Sertraline (lowest dose) for depression/anxiety. I've tried to stop a couple of times and ended up a complete wreck. I switched to trazadone and had such a bad reaction that I had to stop. It put me off trying the other alternative I had in mind which was Reboxetine (there seem to be very few options for RLS friendly antidepressants in the UK). I'm not aware of any others? I stopped the amitriptyline (although strangely my cousin takes it for RLS and it seems to help her). The last serum ferritin reading was a while ago and was 75 ug/l. I was flatly refused an iron infusion by the neurologist who referred me instead to the sleep clinic who wrote immediately to advise they would see me but would not provide an iron infusion (I have another year on the waiting list for that appointment). Due to advice on this forum I try to take 2 iron tablets every other night on an empty stomach with vit C. I'll ask the GP to prescribe codeine in place of tramadol and increase Gabapentin (although I don't seem to tolerate higher doses of any meds which is how I ended up on various meds at lower doses). It's really interesting to know what the parameters are for moving onto opioids like Buprenorphine. I didn't know that. Thank you for all your advice. I would be lost without this forum.
Be sure you don't take magnesium even in a multivitamin within 3 hours of taking gabapentin. Also if you had your ferritin checked 3 months or more ago, you need to have another one. .
Sertraline is an SSRI antidepressant and makes RLS worse for most. Trazodone and Wellbutrin are safe antidepressants for RLS. Trazodone also helps with insomnia. Solpadeine contains caffeine and caffeine for some make RLS worse and for some make it better.
Yes tramadol can cause augmentation for some, but it is not the same augmentation you get from taking pramipexole. so I wouldn't let that terrify you.
You could do any of 4 things 1) increase the gabapentin which usually helps one sleep - you are taking only a starting dose. You should take it 1 to 2 hours before bedtime. If you need more than 600 mg, take the extra 4 hours before bedtime as it is not well absorbed above 600 mg. 2) increase the tramadol. 50 mg is a starting dose 3) Switch to codeine. 30 mg is a starting dose or 4) Ask for buprenorphine which lasts 24 hours as opposed to the codeine and tramadol which can last as little as 4 hours.
Hi Sue, really appreciate your advice and setting out all the options. This sort of detail is invaluable. It's really unfortunate I can't try wellbutrin and that I had such a bad reaction to Trazodone. I was thinking of increasing the gabapentin and asking for codeine to replace the tramadol. Do you have any idea how many codeine I should request as a starting point for replacing 50mg tramadol while increasing gabapentin from 300 to 600? I don't want to leave myself short of medication, particularly when it's so hard to get anything prescribed at all.
Since 30 mg is the starting dose for codeine and 50 mg is the starting dose for tramadol, I would guess they are equivalent and you could switch directly. I would ask your doctor though. The usual effective dose is 60 to 180 mg according to the Mayo Clinic Updated Algorithm on RLS. By the way if you are not familiar with it check it out at Https://mayoclinicproceedings.org/a...
It is a shame trazodone didn't work for you and I know it is hard to get Wellbutrin prescribed in the UK except for smoking cessation.. I would suggest you ask for tianeptine (Stablon, Coaxil) which is safe for RLS.
Thank you so much Sue. Didn't know about Tianeptine. I'll certainly ask. Take care.
Have you had your ferritin checked? If so, what was it? Improving your ferritin to 100 or more helps 60% of people with RLS and in some cases completely eliminates their symptoms. If not when you see your doctor ask for a full iron panel. Stop taking any iron supplements including multivitamins that have iron in them 48 hours before the test, fast after midnight and have your test in the morning. When you get the results, ask for your ferritin and transferrin saturation (TSAT) numbers. You want your transferrin saturation to be over 20% but less than 45% and your ferritin to be at least 100. If they are not, post them here and we can give you some advice.
I gave Jools the serum ferritin reading which was 75.0 ug/l and the transferrin saturation is 28.8% (this test was 2 years ago so I'll have to ask for an updated fasting iron test as you suggest). I didn't realise it's been so long since I had it tested. I don't drink any alcohol and have to watch what I eat because I was diagnosed with celiac a few years ago. The only other thing I am taking is HRT.
HRT contains estrogen and make RLS worse for most.
Meanwhile some things that can make RLS symptoms worse for some people are alcohol, nicotine, caffeine, sugar, carbs, foods high in sodium, foods that cause inflammation, ice cream, estrogen, dehydration, MSG, collagen supplements, electrolyte imbalance, melatonin, stress and vigorous exercise. Some things that help some people include caffeine, moderate exercise, weighted blankets, compression socks, elastic bandages, masturbation, magnesium glycinate, fennel, low oxalate diet, selenium, 5 minute shower alternating 20 seconds cold water with 10 seconds hot water finishing with hot water for another couple of minutes, hot baths, distractions, CBD, applying a topical magnesium lotion or spray, doing a magnesium salts soak, vitamins B1, B3, B6, B12, D3, K2, if deficient, and potassium and copper if deficient, massage including using a massage gun, using a standing desk, listening to music, meditation and yoga.
Many medicines and OTC supplements can make RLS worse. If you are taking any others and you list them here, I can tell you if any make RLS symptoms worse and if so may be able to give you a safe substitute.
I agree with Jools and Sue about the sertraline being the cause of your difficulties. I have taken both codeine and tramadol. They are interchangeable in my experience without any problems. It's unlikely the tramadol is the cause if your difficulties.You could try upping the dose to 100mg for a night to see if it helps. I was on this dose for a long time. I'm on morphine now .Huge good luck.
question what kind of doctor do you go to? A family practice doctor is not the answer. I found a neurologist at a movement center. Best thing I ever did, He understands this. At one point I was over medicating. I’ve tried everything. Had augmentation several times. After my last time we stopped everything and started over. Now I take Pramipexole 1.5 once daily and up to 3 Tramadol daily, Around 5 pm I take my Pramipexole and 2 Tramadol. I then can have another one if needed, if I travel I take an extra tramadol. I never ever take codeine or any antihistamine. I am now trying medical marijuana. I feel bad for you but do understand this.
In the UK, appointments with neurologists are requested via the family practice doctor, but not always approved. The waiting time is about a year. If you pay privately, you can see a neurologist faster, but most in the UK aren't knowledgeable or up to date on RLS, so it can be a waste of time and money.I would suggest you see a different neurologist. Once you have augmented on dopamine agonists, it's simply a matter of time before it happens again.
As you are now on Pramipexole, another dopamine agonist, as soon as you get signs of augmentation, see a neurologist familiar with the Mayo Clinic Algorithm. They do not prescribe Pramipexole or Ropinirole. Most now believe these cause permanent damage to dopamine receptors.
Have a look at Dr Berkowski's website.
I’m a bit curious what you mean when you say you ended up a wreck from going off sertraline. All these meds have psychoactive effects and for instance Tramadol can have an antidepressant effect - pharmacologically, it’s very similar to antidepressants, in fact. It’s not a very good idea to take it together with an antidepressant because you run the risk of inducing too much serotonin. This is called serotonin syndrome, and it can be dangerous. Other opioids and many other drugs including paracetamol can cause it, too, and all this will increase the RLS which will not only make your legs crazy but could also make you feel agitated and moody. You take so many different meds, it’s hard to tell which is doing what (I know, I take many as well since one or two doesn’t help). You just have to be very careful and try and figure out exactly what they do for you and why you’re taking them. Some of us are also very sensitive to dopamine enhancing medications and supplements and so it can all start to work against you. The first thing I would do would be to try and get off the sertraline again, and find some way of coping without it. That’ll make everything else simpler for sure! You may find that you cope better mentally after a while. Oh, and if you’re taking vitamins, it may be a good idea to stop and see what happens. Some of us don’t tolerate certain common vitamins, for instance I get RLS from magnesium and some vitamin B’s.
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