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RLS First-Line Gabapentin Not Dopamine Agonist — ESENeph MCQ

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ModerateHaemodialysisRLS First-Line Gabapentin Not Dopamine AgonistESENeph

A 70-year-old man with CKD G5D on haemodialysis complains of severe restless legs at night, significantly impairing sleep. He has already optimised iron status (ferritin 400 ug/L, TSAT 30%) and dialysis adequacy (spKt/V 1.4). First-line non-pharmacological measures have failed. What is the recommended first-line pharmacological treatment?

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Correct answer: C — Gabapentin at reduced CKD dose

For uraemic restless legs syndrome (RLS) refractory to iron optimisation and dialysis adequacy, gabapentin (or pregabalin) is now recommended as first-line pharmacological therapy rather than dopamine agonists. The 2022 International RLS Study Group and NICE guidance moved away from first-line dopamine agonists due to the risk of augmentation (paradoxical worsening of symptoms with long-term use) and impulse control disorders. Gabapentin dose must be substantially reduced in dialysis patients (e.g., 100-300 mg post-dialysis) as it is renally excreted. Opioids and benzodiazepines are later-line options. Amitriptyline can worsen RLS.

Reference: Allen et al 2022 – RLS Treatment Algorithm; BNF 2024 – Gabapentin Renal Dosing; NICE 2012 – CG79 RLS