Dear Dr. Roach: Short of amputation, what’s the best one can expect in minimizing the sporadic but harsh symptoms of restless legs? — J.M.
Answer: Restless legs syndrome, also called Willis-Ekbom disease, is an underdiagnosed condition. The major symptom involves an overwhelming urge to move the legs, often in conjunction with other symptoms, described as cramping, pulling or tingling. RLS may also be associated with involuntary leg movements during sleep.
The fact that you even joke about amputation gives some idea of how frustrating the symptoms can be, but most people can be treated pretty well, with a marked improvement of symptoms, using behavioral and medication treatments.
Before starting treatment, a simple blood test should be done to check a person’s iron status. Iron deficiency is common in people with RLS, and symptoms can be improved by treating the deficiency. Of course, evaluating why the iron is low may be necessary in people with low iron stores.
Behavioral treatment includes giving advice on good sleeping, regular exercise, a reduction in caffeine and mental exercises during rest. Some medications can worsen RLS. This includes antihistamines (as well as those sold as insomnia aids) and antidepressants of several classes. Antidepressants should not be stopped abruptly, but changing the type of antidepressant may help.
In people with persistent symptoms, treatment may include pramipexole (Mirapex), ropinirole (Requip) or rotigotine (Neupro). These have fewer side effects than others, but may still cause lightheadedness, sleepiness and nausea. These usually get better within a few weeks. Pregabalin (Lyrica) and Horizant (gabapentin enacarbil) are alternatives, and may also be used in combination.
If symptoms are not well controlled on these first-line agents, there are other options available, but consultation with an expert, such as a sleep medicine doctor, would be appropriate.
DEAR DR. ROACH: I’m 82 years old, and I take atorvastatin 10 mg daily. My HDL is 85, triglycerides are 65 and my LDL is 46. I read that these low levels put me at risk for a hemorrhagic stroke. Should I be concerned? — G.G.
ANSWER: Atorvastatin reliably reduces total and LDL cholesterol. It also reduces triglycerides and may raise HDL cholesterol. In many well-done randomized trials, people at high risk for heart disease who took a statin drug had lower rates of heart attack, overall stroke and death than those who took an inactive (placebo) pill. It is true that people with low LDL cholesterol and low triglycerides are at increased risk for hemorrhagic stroke. However, it is not clear that having low cholesterol and triglycerides due to taking a statin is a risk factor for hemorrhagic stroke: The available studies are conflicting.
There are some important additional points I want to discuss. The first is that statins are proven to have benefit in people at high risk, especially those with known blockages in their heart arteries. Those at lower risk will not get as much (or possible any) benefit. The second is that most studies have not included people in their 80s, although most experts do continue to recommend statins in high-risk people, at least until age 85. Third, the dose of atorvastatin you are taking may be higher than you need. Only people at the highest risk for heart attack, such as those with previous heart attacks, are recommended to have the LDL cholesterol so low.
Finally, reducing other risk factors for hemorrhagic stroke, especially elevated blood pressure and excess alcohol use, is particularly important for people with low cholesterol and triglycerides.
