Sherfinski, Emma

Abstract Introduction Restless Legs Syndrome (RLS) affects up to 3% of the adult population in the United States, with approximately one-third of these individuals experiencing medically refractory disease. Historically, treatments for RLS have included iron replacement, dopamine agonists, and alpha-2-delta ligands. However, dopamine agonists are often associated with augmentation, a phenomenon in which RLS symptoms worsen. This includes increased severity, earlier onset, spread of symptoms to other parts of the body, and the need for higher doses of medications. Over the past decade, the use of opioid therapy for refractory RLS has become more widely accepted. Buprenorphine-naloxone, a combination medication, includes buprenorphine, a partial agonist at the mu-opioid receptor, which is less likely to cause respiratory depression, overdose, or euphoria compared to full agonists. Naloxone, an opioid antagonist, is included to deter misuse. Here, we share the treatment responses of three patients with refractory RLS who were treated with buprenorphine-naloxone. Report of case Pre- and post-treatment IRLS were compared in three Sleep Medicine patients (two females, aged 70, and one male, aged 72) on therapeutic doses of buprenorphine-naloxone. Patient charts were reviewed for medication side effects. Previous treatments included dopamine agonists, alpha-2-delta ligands, iron supplementation, benzodiazepines, methadone, and melatonin. Pre-treatment IRLS scores were 13, 13, and 24, classified as moderate to severe. The formulations used included buprenorphine-naloxone 2-0.5 mg sublingual tablets and buprenorphine-naloxone 2-0.5 mg 1/8 films. Therapeutic daily doses of buprenorphine-naloxone ranged from 7.5 to 60 morphine milligram equivalents (MME) per day. Post-treatment IRLS scores were 0, 2, and 3, representing an average reduction of over 15 points on the IRLS. Average time between pre- and post-treatment IRLS was 29 months. Side effects were reported by one patient, including fatigue, depressive symptoms, and reflux, but none of the patients experienced side effects that limited the use of the medication. Conclusion In this case series, we demonstrate the positive impact of buprenorphine-naloxone in managing refractory RLS, as evidenced by substantial reductions in IRLS scores from moderate to severe levels. We hope to encourage clinicians to consider buprenorphine-naloxone as an effective and well-tolerated treatment option for patients with refractory RLS. Support (if any)