Restless Legs Syndrome

A clinical diagnosis — discomfort in the legs (or arms) with a need to keep moving them, typically worse in the evening/early hours, interrupting rest and causing insomnia. Sleep study is not needed. Patients often struggle to describe the sensation; moving the limb gives prompt relief, but symptoms rapidly return.

Prevalence ~15%, more common in women, increasing with age.

Secondary causes / exacerbating factors

Anaemia, iron deficiency, uraemia (rare), hypothyroidism, pregnancy (usually resolves within weeks of delivery); medications — antihistamines, antiemetics, some antidepressants, lithium, antihypertensives, some “tranquilisers.”

Check TFTs, FBC and iron studies, and correct if abnormal.

Initial (non-pharmacological) management

• Stretches — calf stretches against a wall, or lying on the back with a foot in the air, theraband pulling into dorsiflexion.
• A modest walk before bed.
• Good sleep hygiene.
• Avoid evening caffeine, alcohol, smoking.
• Keep legs cooler than the body for sleeping.
• Institute oral or IV iron if ferritin is ≤75 mcg/L or transferrin saturation <20% (IV iron only if ferritin is between 75–100 mcg/L).
• Reduce exacerbating drugs where possible.

Pharmacological management

Mild/infrequent symptoms: often need no drug treatment — lifestyle measures alone are sufficient.

Regular/frequent symptoms — alpha-2-delta ligands are now first-line (see guideline update below):

• Pregabalin 75mg PO nocte, increasing every 3–7 days to max 450mg/day, OR
• Gabapentin 100–300mg PO nocte, increasing every 3–7 days to max 2400mg/day (doses >1200mg: give 1/3 in the evening, 2/3 before bed)

Dopamine agonists — now second-line/intermittent-use only (augmentation risk — see below):

• Levodopa+benserazide or levodopa+carbidopa 100/25mg, up to 200/50mg before bed PRN (Madopar/Sinemet/Kinson) — for intermittent, non-daily use only.
• Pramipexole 125mcg 2–3h before bed, increasing by 125mcg then 250mcg every 4–7 days to max 750mcg/day.
• Ropinirole or rotigotine are alternatives.

Augmentation — symptoms worsening (earlier daily onset, spreading to other body parts) after starting a dopaminergic agent — refer for expert advice; do not simply increase the dose.

If therapy overall is ineffective, refer for expert advice.