A 56 y/o woman presents to the clinic for a routine appointment. Her labs are WNL and vital signs are fine. She has no significant medical history and no allergies. She is on no medications. As she's leaving, she describes this funny feeling she gets in her legs, esp. after she sits down at night to relax before bed. She describes it as an "unpleasant creeping feeling" in her legs. As you discuss this more with her, she relates that moving her legs temporarily helps and these sensations disturb her sleep.

What's her likely diagnosis? What are you going to do to treat it?
 

SELECT  here for discussion

She likely has "restless leg syndrome". The differential diagnosis may include paresthesias/dysesthesias secondary to neuropathy, arthritis, nocturnal leg cramps, akathisia (secondary to neuroleptics), painful legs-moving toes syndrome, radiculopathy, fibromyalgia, vascular insufficiency, anxiety disorder, agitated depression, etc. For the sake of this discussion and keeping it shorter than "War and Peace", we're calling this restless legs syndrome.

Restless Leg Syndrome (RLS) affects between 5 and 20% of the population. It can occur at any age and the prevalence increases with age. It's equally common in men and women and there's not been any racial or ethnic differences established.

Possible treatments - lifestyle changes may help mild cases. Emphasis on good sleep hygiene such as avoiding or eliminating caffeine and/or alcohol, smoking cessation, massage, raising the legs, and flexion/extension movements. Patients who experience RLS-related insomnia, excessive daytime sleepiness, or waking restlessness are reasonable candidates for pharmacotherapy. The most common drugs for this include benzodiazepines (most commonly clonazepam), dopamine agonists, opioids/narcotics, and others. Start low and go slow, increase dose in small increments. Divided doses might be helpful: one with evening meal and second dose at bedtime.

Drug Advantages and Disadvantages   

Dopamine agonists -®, pergolide, pramipexole Effective (70-100%), well tolerated    Nausea, sudden sleepiness, augmentation   

L-DOPA, Sinemet Can be used PRN, good in elderly patients, available generically    Augmentation (up to 82%), insomnia, GI symptoms, rebound

Opioids/narcotics - codeine, propoxyphene, tramadol, Can be used PRN, available generically    Constipation, urinary retention, sleepiness, cognitive changes

Anticonvulsants - gabapentin, carbamazepine (CBZ) Well tolerated. May help in pts with neuropathic pain as well. Improves sleep. CBZ - available generically. Daytime sleepiness. No long term data.

Benzodiazepines - clonazepam, temazepam, triazolam Improves sleep. Some available generically, useful as adjunct. Daytime sleepiness, cognitive impairment esp. in elderly, not for long term treatment.

Clonidine Lessens subjective complaints, useful in hyper-tensive pts, aids falling asleep    Hypotension, dry mouth, drowsiness, may require high divided doses   

The Mayo Sleep Disorders Center has published the following recommendations (Silber, 1997): MILD RLS (symptoms are intermittent or only mildly. Disruptive at onset or maintenance of sleep)

- Benzodiazepines or opioids such as codeine or propoxyphene may be taken intermittently.

MODERATE TO SEVERE RLS (symptoms are continuous and moderately to severely disruptive to onset or maintenance of sleep)

- Levodopa should be initiated.

LEVODOPA RESISTANCE OR INTOLERANCE

- Discontinue levodopa and begin a trial of a dopamine agonist such as pergolide.

DOPAMINE AGONIST RESISTANCE OR INTOLERANCE

- Use higher potency opioids such as oxycodone or methadone.

- Or consider other dopamine agonist, clonidine or gabapentin.

- Some patients may respond to combination therapy such as levodopa with a benzodiazepine.

- Or after a drug-free period, levodopa or pergolide may be reintroduced.

REFERENCE:

- Silber MH: Restless legs syndrome. Mayo Clin Proc 1997; 72(3):261-264

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The US Air Force, the 59th Medical Wing (MDW), and 59th MDW Pharmacy assume no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.