Drug preferred in treatment of 'Restless leg' syndrome?

Ans. B. Ropinirole. (Ref. Harrison 18,h/ch. Table 27-l;Katzung pharmacology 11th7 Ch. 28)Restless Legs Syndrome# It is an unpleasant creeping discomfort that seems to arise deep within the legs and occasionally the arms. It occur particularly when patients are relaxed, especially when they are lying down or sitting, and they lead to an urge to move about. Such symptoms may delay the onset of sleep. A sleep disorder associated with periodic movements during sleep may also occur. The cause is unknown, but the disorder is especially common among pregnant women and also among uremic or diabetic patients with neuropathy. In most patients, no obvious predisposing cause is found, but several genetic loci have been associated with it (12ql2-q21, 14ql3-q31, 9p24-p22, 2q33, and 20pl3).# Symptoms may resolve with correction of coexisting iron-deficiency anemia and often respond to dopamine agonists, levodopa, diazepam, clonazepam, gabapentin, or opiates.# Dopaminergic therapy is the preferred treatment for restless legs syndrome and should be initiated with long-acting dopamine agonists (eg, pramipexole 0.125-0.75 mg or ropinirole 0.25-4.0 mg once daily) to avoid the augmentation that may be associated with levodopa-carbidopa (100/25 or 200/50 taken about 1 hour before bedtime).# Augmentation refers to the earlier onset or enhancement of symptoms; earlier onset of symptoms at rest; and a briefer response to medication. When augmentation occurs in patients receiving an agonist, the daily dose should be lowered or divided, or opioids substituted. Oxycodone is often effective; the dose is individualized.# Gabapentin is an alternative to opioids.Initial dopamine agonists were ergot derivatives (e.g., bromocriptine, pergolide, cabergoline) and were associated with ergot-related side effects, including cardiac valvular damage. They have largely been replaced by a second generation of non-ergot dopamine agonists (e.g., pramipexole, ropinirole, rotigotine). In general, dopamine agonists do not have comparable efficacy to levodopa.Evaluation of the Patient with the Complaint of Excessive Daytime SomnolenceFindings on History and Physical ExaminationDiagnostic EvaluationDiagnosisTherapyObesity, snoring, hypertensionPolysomnography with respiratory monitoringObstructive sleep apneaContinuous positive airway pressure; ENT surgery (e.g., uvulopalatopharyngoplasty); dental appliance; pharmacologic therapy (e.g., protriptyline); weight lossCataplexy, hypnogogic hallucinations, sleep paralysis, family historyPolysomnography with multiple sleep latency testingNarcolepsy- cataplexy syndromeStimulants (e.g., modafinil, methylphenidate); REM-suppressant antidepressants (e.g., protriptyline); genetic counselingRestless legs, disturbed sleep, predisposing medical condition {e.g., iron deficiency or renal failure)Assessment for predisposing medical conditionsRestless legs syndromeTreatment of predisposing condition, if possible; dopamine agonists (e.g., pramipexole, ropinirole)Disturbed sleep, predisposing medical conditions (e.g., ioralasthma), and/or predisposing medical therapies (e.g., theophylline)Sleep-wake diary recordingInsomnias (see text)Treatment of predisposing condition and/ or change in therapy, if possible; behav-therapy; short-acting benzodiazepine receptor agonist (e.g., zolpidem)