N521 Assignment 3 Restless Leg Syndrome Paper

LP is a 23-year-old Hispanic female college graduate who was advised by her workplace colleague to seek medical care following a condition they thought was a ‘fatigue syndrome’ because of suspected symptoms of anemia. LP reports feeling restless and fatigued for nine months now. She has difficulty falling asleep and sometimes her mind ‘goes blank.’ She also reports irritability. These complaints have caused her to be anxious about her life quality and work performance that she thinks have deteriorated since the onset of the symptoms. She has been on contraceptive pills for the past four years and have not caused her any adversities. The disease has not caused disturbances in social life. This paper describes the best possible course of management for this patient.

Most Likely Diagnosis

The patient’s most likely diagnosis is restless leg syndrome. LP’s case is an early onset restless syndrome because the symptoms appear before the age of 45 (Guo et al., 2017). Restless leg syndrome is a neurological disorder, most usually sensorimotor, that has psychological sequelae (Levin & Chauvel, 2019). Restless leg syndrome (RLS) is the most possible diagnosis in this patient because of her “restless” and “on edge” feeling for the nine months, sleep disturbances, fatigue, and irritability. RLS, also known as Willis-Ekbom Disease (WED), is characterized by symptoms worsening later in the day during periods of tranquility especially in the evening or at night (Romero-Peralta et al., 2020). This explains the sleep disturbances in this patient. Her risk factors include female gender (Fred, 2020; Seeman, 2020) and adult age. This condition is more common in adults than children. However, older adults are at more risk of RLS (Guo et al., 2017). The fatiguability in this patient can be attributed to an iron deficiency that is usually considered among the main physiological risks of RLS as mentioned later.

Pharmacotherapeutic Treatment Goals for LP

Identification of specific risk factors is important in determining the management path for patients with RLS. The goals of management of this patient will include reduction in the frequency of restlessness, alleviation of anxiety, improvement in fatigue and irritability, improvement in sleep patterns and durations, and maintenance of proper functional social life. Achievement of these goals will require ruling out extrinsic causes of restless leg syndrome, pharmacological interventions, and proper supportive relationships.

Need for Laboratory Investigations

The Certified Nurse Practitioner (CNP) will require to order laboratory tests for LP. As aforementioned, ruling out extrinsic or physiological causes of RLS would be essential for the achievement of the set therapeutic goals. RLS is associated with iron deficiency and uremia of various causes (Levin & Chauvel, 2019). As a result, the CNP will order for complete blood count and hemoglobin, blood ferritin and iron levels, vitamin B12 levels, serum electrolytes and urea levels, serum creatinine levels, and liver function tests (Ferré et al., 2019). Therefore, performing these investigations in this patient may identify anemia that would have been overlooked and enable directing of treatment towards the elimination of the cause rather than managing the symptomatology.

The Best Drug Therapy for LP

Management of RLS using pharmacotherapy will be determined by the physiology identified. In case there will be unidentified causes, dopamine agonists will remain the best treatment for this patient. This is because she is not on any medications for restless leg syndrome and there is no documented history of adverse reactions to dopamine agonists. LP will be prescribed ropinirole 0.25 mg OD daily NOCTE, 3 hours before bedtime. This dosage may be adjusted depending on the quality of control of the symptoms. Tolerability and patient’s response to the medication would indicate the need to either increase, reduce, or terminate the therapy.

Parameters for Monitoring the Success of the Therapy

The success of the therapy would be monitored by subjective and objective indices. Objective monitoring will include regular assessments of blood pressure and heart rates. These signs would be assessed with posture changes and patient position to watch out for orthostatic blood pressure alterations. Assessment of risk of fall will also be monitored (Guo et al., 2017). Subjective assessment of skin pigmentation and color changes, alertness during the day, symptoms of central nervous system depression, and changes in behavior will also be monitored. Personalized monitoring of frequencies of restlessness symptoms, daily onset, and duration of these symptoms will also be required.

Specific Patient Monitoring Based on the Prescribed Therapy

Monitoring for an overdose would be indicated in this patient as the dose adjustments would be made as appropriate and maximum doses might be required in poor response situations. The presence of hallucinations may indicate serious overdose (Carvalheiro & Maia, 2021). In this patient, specific monitoring of iron stores through serum iron and ferritin levels would be required as they may worsen an impending augmentation due to ropinirole. Even though a disturbance in sleep was a major concern for the patient, daytime somnolence may not indicate positive therapeutic achieving but adverse effect. The presence of daytime drowsiness may require adjustments in dosages. The monitoring of the therapy will be judged by the achievement of the mentioned management goals. Symptom recurrence or worsening may be a major turning point in patient management.

Adverse Reactions that may Require Therapy Change or Termination

Augmentation in ropinirole therapy represents worsening or recurrence of the patient major complaints and symptomatology. This would be shown by an increase in the frequency of occurrence of symptoms or spread of restlessness to other body parts. Pleural and peritoneal fibrosis are some of the adverse effects that may warrant discontinuation of the therapy. Psychotic symptoms and behavioral aggravations such as aggression and delusions would require dose adjustments. Impulse control disorders are major concerns that the CNP should be aware of in ropinirole therapy. These disorders include hypersexuality, pathological gambling, and binge eating. Their presence may signify augmentation or adverse drug reactions that will need discontinuation. In presence of augmentations, the addition of other drugs such as opioids may be required. However, the commonest adverse effects include gastrointestinal (GI) upset such as nausea and vomiting, and other non-GI effects including fatigue and drowsiness.

Anxiety after Six Weeks and Use of Klonopin

LP’s anxiety may persist and when she comes back six weeks later with opinions of using Klonopin, my response would be as follows. LP, in this situation, would be advised that Klonopin would have drug interactions with ropinirole that would worsen her symptoms. She might develop confusion, drowsiness, and an increase in restlessness. Klonopin has been known to cause sleep apnea in some patients (Drugs.com, 2020). As a result, she would not be advised to use Klonopin/clonazepam as it would interfere with her work and social life. Therefore, she would be put on other anxiolytics other than benzodiazepines such as zopiclone or buspirone. Klonopin would only be used as last-line medications for LP.

Health Promotion Activities for LP

Health promotion activities for LP will mainly include lifestyle modifications. She would be advised to do stretching aerobic exercises more often to relieve stress and mild symptoms associated with RLS. She would avoid caffeine, tobacco, and alcohol as these may worsen the symptoms of RLS. The National Institute of Neurological Diseases and Stroke (NINDS) recommends the use of an ice pack or warm bath for the affected part usually the limbs. LP will also be encouraged to do daily massages of the limbs (National Institute of Neurological Disorders and Stroke, n.d.). Dietary improvement will also be encouraged to prevent iron deficiency anemia that would aggravate her condition.

LP’s Long-Term Prognosis

LP’s condition has no cure and the medications and nonpharmacological interventions that are used only improve the quality of life and improve the symptoms. Therefore, LP’s condition is a lifelong disease (Manconi, 2017). Using ropinirole in the long term also risks higher chances of augmentations that would require additional medications that would manage her symptoms. As a result, other medications such as alpha-2-delta agonists may be required and this might increase pill burden that would affect the adherence and treatment compliance.

Conclusion

The most likely diagnosis supported by LP’s presentation is early-onset Restless Leg Syndrome (RLS), also Willis-Ekbom Disease (WED). The presence of sleep disturbance is associated with worsening of restlessness and an urge to move limbs during rest hours. This condition had impacted greatly on her work life and pharmacological interventions would be the best management modality of choice. Therefore, ropinirole, a dopaminergic agonist would be administered, and the dose adjusted appropriately. However, laboratory investigations are required to rule out iron deficiency, uremia, and vitamin deficiencies that are associated with this disease. Adverse effects and augmentation may warrant discontinuation of ropinirole therapy. Unfortunately, this disease is lifelong and there is no cure.

References

Carvalheiro, A. M., & Maia, J. (2021). Ropinirole overdose: Visual hallucinations following misuse: case report. Reactions Weekly, 1846(1), 288–288. https://doi.org/10.1007/s40278-021-92536-6
Drugs.com. (2020). Ropinirole. Drugs.Com. https://www.drugs.com/ppa/ropinirole.html
Ferré, S., García-Borreguero, D., Allen, R. P., & Earley, C. J. (2019). New insights into the neurobiology of restless legs syndrome. The Neuroscientist: A Review Journal Bringing Neurobiology, Neurology and Psychiatry, 25(2), 113–125. https://doi.org/10.1177/1073858418791763
Fred, P. (2020). Restless leg syndrome: The complete encyclopedia on everything you need to know about restless leg syndrome causes, cure, prevention, and management. Independently Published.
Guo, S., Huang, J., Jiang, H., Han, C., Li, J., Xu, X., Zhang, G., Lin, Z., Xiong, N., & Wang, T. (2017). Restless legs syndrome: From pathophysiology to clinical diagnosis and management. Frontiers in Aging Neuroscience, 9. https://doi.org/10.3389/fnagi.2017.00171
Levin, K. H., & Chauvel, P. (2019). Clinical neurophysiology: Diseases and disorders: Volume 161: Handbook of clinical neurology series. Elsevier Science.
Manconi, M. (Ed.). (2017). Restless legs syndrome/Willis Ekbom disease: Long-term consequences and management (1st ed.). Springer.
National Institute of Neurological Disorders and Stroke. (n.d.). Restless legs syndrome fact sheet. Nih.Gov. Retrieved April 26, 2021, from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Restless-Legs-Syndrome-Fact-Sheet