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This is a fictional case based on real-world experience.

Initial Presentation

HISTORY

The patient is a 39-year-old woman, mom of 2, who works full-time as a loan officer at a local bank. She originally presented to her primary care physician with complaints about trouble sleeping and a feeling of “uncomfortable” sensations in her lower legs associated with an urge to move, which relieved the sensations; she recalled similar feelings during her recent pregnancy. Her symptoms begin in the evening and worsen when lying down at bedtime, extending time to fall asleep by 1 to 2 hours, 4x/week.

MEDICAL HISTORY

The patient’s medical history is unremarkable, other than gastric bypass surgery for obesity. She was diagnosed with major depressive disorder (MDD) at age 29 and has been taking bupropion intermittently. She is also being treated for high blood pressure (HBP).

MEDICATIONS

Bupropion 200 mg SR QAM

Lisinopril 20 mg QD

PHYSICAL EXAMINATION

BP: 122/78; Heart rate: 68

Normal weight

Remainder of physical exam unremarkable

NEUROLOGICAL EXAMINATION

Alert with normal speech and cognition

Cranial nerves intact

Normal tone. No tremor or involuntary movements

Normal strength and reflexes

Normal sensation in lower extremities

LABORATORY TESTS

Hgb: 12.6 g/dL

Ferritin: 25 ng/mL

TSAT: 14%

DIAGNOSIS

She was diagnosed with moderate-to-severe restless legs syndrome (RLS). She was educated about RLS, and treatment options were discussed.

Hgb=hemoglobin; QAM=every morning; QD=once daily; SR=sustained release; TSAT=transferrin saturation.

2-YEAR Post initial diagnosis

HISTORY

Shortly after the patient’s initial visit, she was administered intravenous iron 1000 mg due to poor absorption of oral iron revealed in her iron results. The ferritin (>100 ng/mL) and TSAT (>20%) moved into the desirable range for people with RLS, however; there was no improvement in her RLS symptoms after 3 months.

At that point, ropinirole (titrated up to 2 mg/day and dosed 2 hours before bedtime) was initiated. She experienced an immediate improvement of night-time symptoms and was sleeping well. However, in the past 6 months she reports that while still working well in the evening and at bedtime, she is having awakenings through the night, at which time she often has restless legs which interfere with return to sleep for over 1 hour.

PHYSICAL EXAMINATION and NEUROLOGICAL EXAMINATION

Unchanged

LABORATORY TESTS

Hgb: 13.9 g/dL
Ferritin: 210 ng/mL
TSAT: 25%

3-YEAR POST INITIAL DIAGNOSIS

HISTORY

The patient’s dose of ropinirole was increased to 4 mg/day (2 hours before bed) with immediate improvement of night-time RLS symptoms and sleep. However, in the past 3 months, she has experienced an earlier onset of symptoms such that she is using a standing desk at work and may need to pull over on the commute home to alleviate the uncomfortable sensation in her legs. Furthermore, the uncomfortable sensations in her legs have increased in severity and are now also being experienced in her shoulders and forearms.

PHYSICAL EXAMINATION and NEUROLOGICAL EXAMINATION

Unchanged

LABORATORY TESTS

Normal CBC and hemoglobin
Ferritin: 195 ng/mL
TSAT: 24%

The Evolution of Restless Legs Syndrome (RLS) Management:

A Problem-based Learning Approach

Objectives

presented by

John Winkelman, MD, PhD

Please scroll down to access the video presentation controls and to see more information on RLS and Azurity Pharmaceuticals. Once the video begins, questions will appear on the right as we get to decision points in the case.

Initial Presentation

HISTORY

MEDICAL HISTORY

MEDICATIONS

PHYSICAL EXAMINATION

NEUROLOGICAL EXAMINATION

LABORATORY TESTS

DIAGNOSIS

2-YEAR Post initial diagnosis

HISTORY

PHYSICAL EXAMINATION and NEUROLOGICAL EXAMINATION

LABORATORY TESTS

3-YEAR POST INITIAL DIAGNOSIS

HISTORY

PHYSICAL EXAMINATION and NEUROLOGICAL EXAMINATION

LABORATORY TESTS