A 65-year-old man comes to the physician for difficulty falling asleep. He experiences discomfort in the lower extremities and a strong urge to move his legs, which occurs just as he is about to fall asleep. His wife is awakened because of his excessive leg movements. The patient has no headaches, tremors, weakness, or numbness. He has hypertension and takes lisinopril and daily low-dose aspirin. He is a chronic smoker but does not use alcohol or illicit drugs.
Vital signs and neurological examination are unremarkable.
A complete blood count and serum iron studies are normal.
Which of the following is the best initial treatment for this patient's condition?

Question

A 65-year-old man comes to the physician for difficulty falling asleep.  He experiences discomfort in the lower extremities and a strong urge to move his legs, which occurs just as he is about to fall asleep.  His wife is awakened because of his excessive leg movements.  The patient has no headaches, tremors, weakness, or numbness.  He has hypertension and takes lisinopril and daily low-dose aspirin.  He is a chronic smoker but does not use alcohol or illicit drugs.
Vital signs and neurological examination are unremarkable.
A complete blood count and serum iron studies are normal.
Which of the following is the best initial treatment for this patient's condition?

Quizplus · Accepted Answer

11ec193a_988f_2bcf_853d_b1688e9522d3_MD0002_00 This patient, with lower-extremity discomfort, urge to move the legs when falling asleep, and nocturnal leg movements, has typical features of restless leg syndrome (RLS). Clinically, RLS is characterized by an irresistible urge to move one's body, typically the legs, to stop uncomfortable or odd sensations. The symptoms are worsened by attempts at relaxation and falling asleep. RLS is more common in middle-aged and older patients, as well as those with chronic kidney disease and/or iron deficiency anemia. Treatment options RLS include dopaminergic agonists (ropinirole, pramipexole) or gabapentin. Levodopa may also be considered for patients who only need occasional treatment. Supplemental interventions that may be considered include iron supplementation (if low ferritin), in addition to nonpharmacologic interventions such as leg massage, warm or cold compresses, sleep hygiene measures, and regular exercise. (Choice A) Benztropine is an anticholinergic drug indicated for the treatment of parkinsonism and drug-induced extrapyramidal disorders. It has not been well studied for use in RLS. (Choice B) Benzodiazepines and opiates are helpful in RLS, but sedation and tolerance limit their use. They are used primarily as second-line therapy or for patients with only occasional symptoms. (Choice C) Clozapine and other dopamine receptor blockers (eg, haloperidol) may not help RLS and could worsen symptoms. (Choice E) Valproic acid has been studied for use in RLS, but evidence is limited and potential toxicity likely outweighs benefit for most patients. Educational objective: Dopaminergic agonists (ropinirole, pramipexole) are the mainstays of treatment for restless leg syndrome. __________ References: Treatment of restless legs syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/23703310) Treatment of restless legs syndrome: an evidence-based review and implications for clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/18925578)

A 65-Year-Old Man Comes to the Physician for Difficulty Falling