Restless Legs

Restless legs syndrome is characterised by dysesthesia in the legs followed by an overwhelming urge to move the legs, made worse by sitting or lying, made better by walking, and usually worse at night. It is more common in 3 groups of people: 1) hereditary RLS; 2) women in the third trimester of pregnancy; and 3) end stage kidney disease.

General management advice

• Intradialytic exercise, such as cycling, can be helpful.
• Ensure patients are iron replete.
• Check for medications that can cause or exacerbate RLS such as metoclopramide and haloperidol.

Pharmacological management

There are 2 main classes of pharmacological therapy.

1.  Gabapentinoids (gabapentin or pregabalin)

Gabapentinoids are preferred due to their efficacy for other symptoms such as peripheral neuropathy and uraemic pruritus.

Commence gabapentin 100mg or pregabalin 25mg alternate nights for non-dialysis (eGFR<15ml/min) and peritoneal dialysis patients, or 3x weekly post-dialysis for haemodialysis patients. For patients symptomatic during haemodialysis, additional dose can be given 1hr before commencement of dialysis.

If limited efficacy, titrate up to gabapentin 100mg nocte or pregabalin 25mg nocte. However, if up-titration causes side-effects, particularly somnolence, or symptom is clearly resistant, commence dopamine agonists.

Doses above gabapentin 300mg nocte or pregabalin 50mg nocte can be associated with significant side-effects for ESKD patients, and specialist advice is recommended with further dose up-titration.

2.  Non-ergot dopamine agonist (ropinirole or pramipexole)

Commence Ropinirole 0.5mg nocte. If ineffective, uptitrate to 1mg nocte, then to 2mg nocte.

The alternative, pramipexole, is commenced at 0.25mg nocte. Dose can be up-titrated to efficacy, keeping in mind that pramipexole can accumulate in renal failure.

2 particular side-effects are worth noting:

• • Augmentation, an onset of RLS earlier than normal, eg early evening or late afternoon
  • Rebound, good efficacy overnight with medication, and patient waking in the morning with restless legs.

If either occurs, trial switching to gabapentinoids, dividing or advancing the dose of dopamine agonist, such as administration at 6pm instead of bedtime.

Other aberrant behavioural abnormality are uncommon.

For difficult cases, consult specialist palliative care.

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