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RLS Second-Line Dopamine Agonist — ESENeph MCQ

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ModerateHaemodialysisRLS Second-Line Dopamine AgonistESENeph

A 65-year-old man with CKD G5D on HD develops worsening restless legs despite iron optimisation. He is started on Gabapentin 100 mg after each HD session. After 4 weeks symptoms persist. What is the next step?

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Correct answer: A — Add low-dose Ropinirole or Pramipexole (dopamine agonist) as second-line therapy

When iron optimisation and first-line Gabapentin/Pregabalin fail for uraemic RLS, low-dose dopamine agonists (Ropinirole 0.25-2 mg, Pramipexole 0.088-0.5 mg) at bedtime are second-line. They act on dopaminergic pathways involved in RLS pathogenesis. Augmentation (worsening symptoms with long-term use) is a concern with dopamine agonists. Levodopa has higher augmentation rates than dopamine agonists. Opioids (low-dose Codeine) are third-line. Kidney transplantation often cures uraemic RLS.

Reference: NICE CG176 – RLS; KDOQI 2015 – HD; Allen and Earley 2018