A 57-year-old woman comes to the physician at the insistence of her husband; he reports that for quite some time, she has been extremely agitated when sitting, resting, or lying down at night. She has trouble falling asleep in bed, which in turn keeps him awake. The patient's discomfort occurs every night; she describes it as an "internal itch that creeps up my lower legs and is often so uncomfortable that I could cry." This strange sensation compels her to stand and pace the floor, and worsens when she feels fatigued. Her medical history is significant for well-controlled hypertension, gastroesophageal reflux disease, allergic rhinitis, and tension headaches. The patient has been on amlodipine, omeprazole, and ibuprofen for 3 years with no recent changes in dosage. She does not smoke or use illicit drugs but consumes 1-2 alcoholic drinks on weekends. There is no family history of similar problems. Physical examination is unremarkable. The appropriate study was ordered and the results are within normal limits. Which of the following medications should be prescribed at this time?

Question

A 57-year-old woman comes to the physician at the insistence of her husband; he reports that for quite some time, she has been extremely agitated when sitting, resting, or lying down at night.  She has trouble falling asleep in bed, which in turn keeps him awake.  The patient's discomfort occurs every night; she describes it as an "internal itch that creeps up my lower legs and is often so uncomfortable that I could cry."  This strange sensation compels her to stand and pace the floor, and worsens when she feels fatigued.  Her medical history is significant for well-controlled hypertension, gastroesophageal reflux disease, allergic rhinitis, and tension headaches.  The patient has been on amlodipine, omeprazole, and ibuprofen for 3 years with no recent changes in dosage.  She does not smoke or use illicit drugs but consumes 1-2 alcoholic drinks on weekends.  There is no family history of similar problems.  Physical examination is unremarkable. The appropriate study was ordered and the results are within normal limits.  Which of the following medications should be prescribed at this time?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c186_091f_8f63_53619e74f094_MD0005_00 Restless legs syndrome (RLS) can be classified as intermittent, daily, and refractory. Intermittent or daily RLS of mild severity is often treated with non-pharmacologic methods including iron replacement therapy, mentally stimulating activities (eg, crossword puzzles), and the avoidance of exacerbating factors (eg, nicotine, alcohol, caffeine). In moderate-to-severe daily RLS (as seen in this patient), dopamine agonists such as pramipexoleor ropinirole are considered first-line therapy. Second-line choices include benzodiazepines (eg, clonazepam) and gabapentin (Choices A and C). Benzodiazepines are typically used in patients requiring intermittent therapy only or as treatment augmentation in refractory cases. (Choice B) Although opioid abuse potential is thought to be low in patients with RLS, prescription of narcotics is typically restricted to those patients with severe treatment refractory symptoms. (Choice D) Levodopa has been shown to cause "augmentation" in RLS patients, which is the paradoxical worsening (occurring earlier in the day, spreading to other body parts, shorter latency to symptom onset at rest) of RLS symptom severity. For this reason, levodopa is primarily recommended for intermittent RLS because as needed use may decrease the risk of developing augmentation symptoms. Educational objective: First-line treatment for daily restless legs syndrome of moderate-to-severe intensity includes dopamine agonists such as pramipexole or ropinirole. References: The restless legs syndrome and periodic limb movement disorder: a review of management. (http://www.ncbi.nlm.nih.gov/pubmed/15449218)

A 57-Year-Old Woman Comes to the Physician at the Insistence