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Restless Legs Syndrome (RLS) is a neurological disorder characterized by an irresistible urge to move the legs, usually accompanied by uncomfortable sensations (Wijemanne & Jankovic, 2015). These sensations typically occur in the evening or at night during periods of rest and can significantly impact sleep quality and overall quality of life. RLS can exist as a primary disorder or be secondary to other conditions, and its management can be particularly challenging in patients with comorbid conditions such as ADHD, anxiety, depression, and insomnia (Earley & Silber, 2010).
A 42-year-old male with a past medical history significant for ADHD, anxiety, depression, insomnia, and Restless Legs Syndrome (RLS) sought a second opinion at a sleep medicine clinic regarding his RLS management. His symptoms were under control with 0.5mg BID Ropinirole, yet the patient desired to discontinue this medication due to concerns about augmentation. Despite a proposed alternative of Gabapentin, he ceased its use after discovering potential side effects related to dementia—a significant worry given his extensive family history of the condition. Additional pertinent history revealed a severely decompensated state of ADHD, which, according to his psychiatric team, contraindicated the use of stimulants. A further complication was his inability to adhere to Cognitive Behavioral Therapy for Insomnia (CBT-I) and to establish care with a specialized psychotherapist. Although his Ferritin levels were within normal ranges and a sleep study ruled out sleep apnea, the patient’s therapeutic pathway remained complex. An initial trial of Pregabalin 100mg at bedtime was swiftly abandoned by the patient after a single dose. Following this, our team introduced a lower dose of Pregabalin at 50mg nightly, with the patient self-adjusting to a bi-nightly regimen for three days alongside his ongoing Ropinirole. This co-administration proved intolerable when attempting to decrease the Ropinirole dosage, escalating the patient’s distress and worsening his RLS symptoms—evidenced by frequent early morning communications with the sleep medicine team. In response, we added Clonidine 0.2mg nightly, a centrally acting alpha-2 agonist typically utilized for hypertension but also noted for its off-label application in treating insomnia and ADHD in children. Maintaining Pregabalin at 50mg bi-nightly and initiating a gradual Ropinirole taper resulted in significant improvement. The patient successfully reduced his Ropinirole to 0.25mg nightly, marking a breakthrough in his symptom management.
Our case highlights the difficulty of managing RLS with psychiatric comorbidities, demonstrating a complex therapeutic pathway involving various pharmacological interventions and the challenges of polypharmacy and augmentation (Umbreit et al., 2021). It underscores the potential for off-label medication use in such complex cases, advocating for a personalized approach to RLS treatment that accommodates the broad spectrum of patient needs and preferences.
References:
Wijemanne, S., & Jankovic, J. (2015). Restless legs syndrome: clinical presentation diagnosis and treatment.. Sleep medicine, 16 6, 678-90 . https://doi.org/10.1016/j.sleep.2015.03.002.
Earley, C., & Silber, M. (2010). Restless legs syndrome: understanding its consequences and the need for better treatment.. Sleep medicine, 11 9, 807-15 . https://doi.org/10.1016/j.sleep.2010.07.007.
Umbreit, A., Sinha, S., Kolla, B., & Mansukhani, M. (2021). Challenges in the Treatment of Restless Legs Syndrome: A Case Report. Journal of Primary Care & Community Health, 12. https://doi.org/10.1177/21501327211019590.
