A 38-year-old woman with multiple sclerosis comes to the office due to insomnia for the past several weeks. The patient also reports episodes of an uncomfortable "tingly" sensation in her legs associated with an urge to stretch her legs or move around. The symptoms are worse when she is lying in bed at night or when watching television or working at her computer. The patient began taking over-the-counter antihistamines to help her sleep but states she wakes up a few hours later with worsening symptoms. She feels exhausted and foggy-headed during the day. The patient is taking a stable-dose disease-modifying treatment for multiple sclerosis, and her most recent exacerbation was 2 years ago. She has no other medical conditions. Physical examination shows mildly increased lower extremity reflexes but normal muscle strength and sensations. Which of the following is the most appropriate pharmacotherapy for this patient's current symptoms?

Question

A 38-year-old woman with multiple sclerosis comes to the office due to insomnia for the past several weeks.  The patient also reports episodes of an uncomfortable "tingly" sensation in her legs associated with an urge to stretch her legs or move around.  The symptoms are worse when she is lying in bed at night or when watching television or working at her computer.  The patient began taking over-the-counter antihistamines to help her sleep but states she wakes up a few hours later with worsening symptoms.  She feels exhausted and foggy-headed during the day.  The patient is taking a stable-dose disease-modifying treatment for multiple sclerosis, and her most recent exacerbation was 2 years ago.  She has no other medical conditions.  Physical examination shows mildly increased lower extremity reflexes but normal muscle strength and sensations.  Which of the following is the most appropriate pharmacotherapy for this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d581_c0d3_bc81_8ba9ea8bb53b_MD0003_00 This patient has insufficient sleep due to nighttime leg discomfort that is temporarily alleviated by movement. This presentation raises suspicion for restless legs syndrome (RLS), which is classified as primary (if idiopathic) or secondary (if accompanied by associated chronic disease or medications). The patient's multiple sclerosis (MS), disease-modifying medications, and antihistamine use may be contributing to RLS symptoms. RLS is characterized by dysesthesia (eg, crawling and itching feelings) and an irresistible urge to move the legs when at rest. Symptoms occur primarily in the evenings and at night; they are partially relieved by movement. RLS does not cause pain or symptoms of peripheral neuropathy (eg, numbness). Although its exact pathophysiology is unclear, RLS appears to be associated with central and peripheral nervous system changes. In the CNS, impaired iron use and dopaminergic systems (located close to the circadian control centers) may play a role; peripherally, hyperalgesia is partly mediated by A-delta fiber input. Patients with intermittent or mild symptoms usually improve with nonpharmacologic therapy (eg, leg massage, sleep hygiene). If pharmacotherapy is required, dopamine agonists such as pramiprexole are often effective. Alpha-2-delta calcium channel ligands, such as gabapentin, are also commonly used. In addition, control of chronic disease and iron supplementation (eg, for serum ferritin ≤75 µg/L) often improve symptoms. (Choice A) In patients with MS, baclofen is an effective treatment for spasticity, which can cause hyperreflexia and leg discomfort. However, nocturnal symptoms, urge to move the legs, and temporary relief with walking make RLS more likely. spasticity (Choice B) Benzodiazepines are not typically used in RLS due to the risks of sedation, tolerance, and potential for abuse. They are sometimes used to manage akathisia, which can cause restlessness and inability to sit still; however, akathisia typically is not worse at night or at rest and is an extrapyramidal symptom of antipsychotic drugs. (Choices C and D) Fluoxetine and duloxetine are used to treat MS-associated depression, which can present with fatigue. However, this patient's fatigue is due to insufficient sleep. Although patients with MS and/or RLS often have comorbid psychiatric disorders that can interfere with sleep, psychiatric disorders do not cause evening leg discomfort temporarily relieved by walking. Duloxetine is sometimes used for peripheral neuropathy, which typically causes pain and is not associated with an urge to move. Educational objective: Restless legs syndrome is characterized by an urge to move the legs with discomfort that is temporarily relieved by movement. Dopamine agonists (eg, pramipexole) are often effective. References: Restless legs syndrome: from pathophysiology to clinical diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/28626420) Differential diagnosis and treatment of restless legs syndrome: a literature review. (http://www.ncbi.nlm.nih.gov/pubmed/30443467)

A 38-Year-Old Woman with Multiple Sclerosis Comes to the Office