From the Guidelines
For an 81-year-old male with worsening Restless Legs Syndrome (RLS) and shooting pain on ropinirole 2mg TID and duloxetine 120mg QD, I recommend optimizing his medication regimen by reducing the ropinirole dose to 1mg TID and reintroducing gabapentin at 300mg at bedtime, slowly increasing to 300mg TID as tolerated, as suggested by the American Academy of Sleep Medicine clinical practice guideline 1. This approach is based on the most recent and highest quality study available, which provides conditional recommendations against the standard use of ropinirole due to the risk of augmentation with long-term use 1. The use of gabapentin is supported by the guideline, which suggests its use in adults with RLS, particularly in those with end-stage renal disease (ESRD) 1. Additionally, alpha-2-delta ligands like gabapentin or pregabalin are effective for both RLS and neuropathic pain, as noted in the guideline and other studies 1. Some key points to consider in the management of this patient include:
- Reducing the ropinirole dose to prevent augmentation, which can worsen symptoms with long-term dopamine agonist use
- Reintroducing gabapentin at 300mg at bedtime, slowly increasing to 300mg TID as tolerated
- Checking iron status, as ferritin levels below 75 ng/mL can exacerbate RLS, and supplementing with iron if needed
- Maintaining good sleep hygiene, avoiding caffeine and alcohol, and ensuring regular moderate exercise
- Considering alternative treatments, such as bilateral high-frequency peroneal nerve stimulation, which receives a conditional recommendation from the guideline 1. It is essential to prioritize the patient's quality of life, morbidity, and mortality when making treatment decisions, and to carefully weigh the potential benefits and risks of each medication, as noted in the studies 1.
From the FDA Drug Label
2.3 Dosing for Restless Legs Syndrome The recommended adult starting dose for RLS is 0.25 mg once daily 1 to 3 hours before bedtime. After 2 days, if necessary, the dose can be increased to 0.5 mg once daily, and to 1 mg once daily at the end of the first week of dosing, then as shown in Table 2 as needed to achieve efficacy. Titration should be based on individual patient therapeutic response and tolerability, up to a maximum recommended dose of 4 mg daily. When discontinuing ropinirole tablets in patients with RLS, gradual reduction of the daily dose is recommended [see Warnings and Precautions (5.85. 9)].
The patient is currently taking ropinirole 2mg three times a day (TID), which is higher than the recommended maximum dose of 4mg once daily for Restless Legs Syndrome (RLS).
- The patient's dose should be reduced to the recommended maximum dose of 4mg once daily to minimize potential adverse effects.
- The patient should be monitored closely for signs of withdrawal or worsening of symptoms when reducing the dose.
- Alternative treatments or adjunctive therapies may be considered if the patient's symptoms are not adequately controlled with the recommended dose of ropinirole.
- Duloxetine and gabapentin may be considered as adjunctive treatments for RLS, but their use should be carefully evaluated and monitored due to potential interactions and side effects 2.
From the Research
Management of Restless Legs Syndrome (RLS) and Shooting Pain
The patient is currently experiencing increasing RLS and shooting pain while on ropinirole 2mg TID and duloxetine 120mg QD. To manage and tweak the medications, consider the following options:
- Re-evaluate the patient's iron status, as iron deficiency can exacerbate RLS symptoms 3, 4
- Consider adjusting the dose of ropinirole, as the current dose may not be sufficient to control symptoms 5
- Gabapentin, which the patient was previously on, may be reconsidered as an alternative or adjunct therapy, especially if the patient experienced relief from shooting pain while on this medication 5, 6
- Duloxetine, an serotonin-norepinephrine reuptake inhibitor, may be continued, but its efficacy in managing RLS symptoms should be monitored 3
- Other treatment options, such as pregabalin, pramipexole, or rotigotine, may be considered if the patient's symptoms are not adequately controlled with current medications 3, 7
- Combination therapy may be necessary for patients with severe RLS symptoms, but this should be approached with caution due to the potential for increased side effects 7, 6
Potential Side Effects and Considerations
When managing RLS and shooting pain, it is essential to consider the potential side effects of medications, including: