From the Guidelines
Quinine is not a suitable treatment for leg cramps in patients with End-Stage Renal Disease (ESRD) on Hemodialysis due to its potential serious side effects and significant drug interactions. The American Academy of Sleep Medicine (AASM) clinical practice guideline 1 does not mention quinine as a recommended treatment for restless legs syndrome (RLS) or periodic limb movement disorder (PLMD) in adults with ESRD. Instead, the AASM suggests the use of gabapentin over no gabapentin in adults with RLS and ESRD (conditional recommendation, very low certainty of evidence) 1. Key considerations for treating leg cramps in ESRD patients include:
- Proper hydration
- Stretching exercises before dialysis
- Vitamin E supplementation
- Ensuring adequate dialysis If medication is necessary, gabapentin or other alternatives may be considered at reduced doses appropriate for renal impairment. It is essential for patients to discuss any leg cramp symptoms with their nephrologist to develop an individualized treatment plan that addresses their specific needs while minimizing risks.
From the FDA Drug Label
Quinine sulfate capsules use for the treatment or prevention of nocturnal leg cramps may result in serious and life-threatening hematologic reactions, including thrombocytopenia and hemolytic uremic syndrome/thrombotic thrombocytopenic purpura (HUS/TTP). Chronic renal impairment associated with the development of TTP has been reported. The risk associated with quinine sulfate capsules use in the absence of evidence of its effectiveness in the treatment or prevention of nocturnal leg cramps outweighs any potential benefit [ see Indications and Usage (1)and Warnings and Precautions (5.1)].
Quinine is not a suitable treatment for leg cramps in patients with End-Stage Renal Disease (ESRD) on Hemodialysis, due to the risk of serious and life-threatening hematologic reactions, including thrombocytopenia and HUS/TTP, which can be exacerbated by chronic renal impairment 2 2.
From the Research
Quinine as a Treatment for Leg Cramps in ESRD Patients on Hemodialysis
- Quinine sulfate has been used to treat leg cramps in patients with End-Stage Renal Disease (ESRD) on hemodialysis, but its effectiveness and safety are debated 3, 4, 5.
- Some studies suggest that quinine can reduce the frequency and severity of leg cramps in these patients, possibly by decreasing the excitability of the motor end plate and reducing muscle contractility 3.
- However, other studies have raised concerns about the efficacy and safety of quinine, citing design flaws in trials and a high risk of toxicity, particularly in patients with renal failure 4, 5.
- The FDA has restricted the use of quinine for leg cramps due to concerns about its efficacy and safety profile 4.
Alternative Treatments for Leg Cramps in ESRD Patients on Hemodialysis
- Several alternative treatments have been proposed for leg cramps in ESRD patients on hemodialysis, including verapamil, gabapentin, carisoprodol, and orphenadrine 4.
- Vitamins C and E have also been shown to be effective in reducing the frequency, severity, and duration of dialysis-related muscle cramps 6.
- L-carnitine is a promising intervention that warrants further investigation 6.
- Gabapentin has been shown to be effective in relieving symptoms of restless leg syndrome and improving quality of sleep and life in ESRD patients undergoing hemodialysis 7.
Considerations for Quinine Use in ESRD Patients on Hemodialysis
- Quinine should be used with caution in ESRD patients on hemodialysis, particularly in those with renal failure, and should be avoided in patients with liver disease 3.
- A dosage of 200 to 300 mg of quinine every night has not been shown to cause significant side effects, but patients should be closely monitored for adverse effects 3.
- Given the limited evidence and potential risks, quinine should not be considered a first-line treatment for leg cramps in ESRD patients on hemodialysis 4, 5.