restlessknight wrote:I take the following; 5mg oxycocdon, 1mg pramipexle,and 300mg gabapentin.
I took 4mg of pramipexle for a while but augmentation was a concern. My Neurologist also presented a study showing it actually my cause RLS/PLMS to possibly progress more rapidly.
restless, even though you wisely decreased your dose of pramipexole, and that has to be helping you, you never stopped the DA completely, so your dopamine system is probably still out of whack. Your dopamine system doesn't "re-set" until some time after the pramipexole or other DA is stopped completely. The time required is usually a couple of weeks, but can be longer.
Plus, your current 1mg dose is 4x higher than the 0.25 mg maximum recommended by most RLS/WED specialists. There is a link below my name under every post I write, from which you can download a paper by Dr Buchfuhrer in which he makes these recommendations, which are now accepted by most other specialists. The whole paper might be of interest to you (and you should print it for your doctor - or better still, get the Foundation's Medical Bulletin) but here is the relevant part:
Although the FDAapproved,
maximum doses for ropinirole and pramipexole
are 4 mg and 0.75 mg, respectively; many physicians exceed
this dose, especially when treating daytime symptoms that
may require 1 or 2 additional doses per day. However, after
10 to 15 years of experience with these drugs, concerns
regarding augmentation of RLS symptoms by these drugs
have made many RLS experts rethink the doses used to treat
RLS, and even whether these drugs should be first-line
drugs of choice for this disease. Due to concerns regarding
augmentation of RLS, In the opinion of this author and
several other RLS experts, the maximum doses of dopamine
agonists should be much lower than the approved FDA
doses (such as 0.25 mg for pramipexole and 1 mg for
ropinirole).
I am not familiar with the study that suggests the WED/RLS may progress more rapidly when taking DAs but I do know that the personal experience of a lot of us, and the thoughts of a number of RLS/WED specialists, are that taking DAs or augmenting from them can cause permanent or long-term damage to the dopamine system in the body. For instance, these comments by Hening, Early, Chokroverty and Allen (book) about DA augmentation:
"There is a concern that augmentation represents a significant disruption of the dopaminergic system that may become a major problem for the patients later in life. The delayed onset of augmentation suggests some slow but persistenly developing proces disrupting dopaminergic function. We assume that at some critical point this process stabilizes and does not continue causing dopaminergic disruption. But the delay in expression of the problem may reflect a slow, persistent process continuing indefinately. In such a situation the effects of this slow, persistent process could be masked for years by slow increases in doses of the DA's. It will take several years of extensive clinical experience treating RLS with these meds before we will know the long-term sinificance, if any of RLS augmentation".
If you read the definition of augmentation, you may be able to deduce for yourself if you were experiencing it at 4 mg and if you still are. Augementation is a paradoxical worsening of symptoms caused by the dopmaine-type drugs (Sinemet/levo-carbidopa, Mirapex/pramipexole, Requip/ropinirole). It is very likley to happen in people with low ferritin levels, and is more likley at higher doses of the medication. It is also more likely the longer you've been taking a dopamine-type drug. Once you have it, increasing the dose might help temporarily but eventually increases the augmentation. Sometimes the augmentation can be controlled (for a while anyway) by an additional, earlier dose. If you have augmenation, your regular evening dose still works, but you start developing symptoms earlier in the day, or in more body parts, or you get more severe symptoms.
{{{{{{{{{{{Technically, for you to be augmenting:
1. All of the following must be true:
- you have had an increase in symptom severity as compared with when you started treatment
- the increase in symptom severity cannot be accounted for by other factors (change in medical status, lifestyle, natural progression of the disorder)
- there was a prior positive response to treatment
2. Also, either A or B has to be true:
A. persisting paradoxical response to treatment: WED/RLS symptom severity increases some time after a dose increase and improves some time after a dose decrease; or
B. earlier onset of symptoms. This can mean either an earlier onset by at least 4 hours
OR and earlier onset by 2-4 hours accompanied by one of the following:
- shorter latency to symptoms when at rest, as compared to before treatment
- extension of symptoms to other body parts, as compared to before treatment
- greater intensity of symptoms, as compared to before treatment
- shorter duration of relief from treatment, as compared to before treatment
}}}}}}}}}}}
Here's an interesting quote:
Severe augmentation invariably causes such distress that people are desperate for relief. Increasing medications further provides little relief and may ultimately intensify symptoms. Stopping the drug will eventually relieve the augmentation, but this may take some time - leaving the patient in great distress. The time it takes for the effects of augmentation to wear off can be quite variable, lasting several days to weeks. Opiods can be used short term to control the intense RLS symptoms in these cases. There are other options for therapy once the effects of augmentation have resolved......
From: Buchfuhrer, Hening, and Kushida, 2007. Restless Legs Syndrome. American Academy of Neurology Press, Quality of Life Guides, Demos Medical Publishing, New York, p. 106.
There is more information on augmentation and critically, on ferritin levels and the role of iron in WED/RLS, in the link under my name below.