1224 Management of Dopaminergic Augmentation of Restless Legs Syndrome with Concurrent High Dose Benzodiazepine Therapy

Abstract

Abstract Introduction Restless Legs Syndrome (RLS) or Willis-Ekbom disease, is sleep related movement disorder characterized by an irresistible urge to move the legs, often accompanied by uncomfortable and unpleasant sensations. Over the years, dopaminergic agonists (DAs) have served as the primary treatment for RLS. However, the emergence of dose-dependent augmentation has prompted a shift in the management approach. This change is marked by a growing emphasis on prioritizing alpha2-delta calcium channel ligands (A2D) as alternative therapeutic agents Report of case(s) We report a case of a 70-year-old woman with a 15-year history of RLS, with crawling and unpleasant sensation of her legs preventing from falling asleep, successfully managed initially with pramipexole 0.5mg at night and eventually started on clonazepam. With escalating symptoms, Pramipexole and Clonazepam gradually increased. Despite dose escalation of pramipexole to 0.75mg and clonazepam to 4mg nightly, symptoms persisted and even intensified. Abruptly discontinuing Pramipexole and transitioning to ropinirole at 1mg and continuing Clonazepam 4mg nightly failed to yield improvement. Patient presented for consultation at this time highlighting the severity of RLS augmentation as moderate. Recommendation in this situation is to introduce A2D or possible opiate medication to ameliorate symptoms before tapering DA. The patient's high-dose benzodiazepine regimen increases respiratory depression and fall risk, hindering the standard approach of introducing alternative agents. In response, a tailored strategy was implemented, gradually tapering clonazepam while initiating gabapentin therapy, RLS symptoms began to improve. Subsequent cautious tapering of ropinirole contributed to sustained relief. This case demonstrates the need for individualized approaches in managing dopaminergic augmentation in RLS, especially when high-dose benzodiazepines are involved. Conclusion In navigating the intricacies of RLS treatment, our case highlights the effectiveness of a nuanced approach when confronted with dopaminergic augmentation alongside concurrent high-dose benzodiazepine therapy. Tapering benzodiazepines and introducing gabapentin proved successful, emphasizing the importance of tailored interventions. This case contributes to the understanding of RLS management in complex scenarios. Support (if any)