When should I consider prescribing medication for a patient with recurrent nocturnal leg cramps?

Consider prescribing medication for recurrent nocturnal leg cramps only if:

• Treatable causes of cramps have been excluded.
• The cramps are very painful and frequent.
• The cramps significantly affect the person's quality of life, for example by regularly disrupting sleep.
• Self-care measures such as stretching exercises have failed to provide relief.
• The person has no medical conditions or drug interactions that increase the risk of medication side effects.
• Potential adverse effects of the medication have been discussed and the patient is willing to be carefully monitored.

Quinine is generally not recommended for routine use due to a poor benefit-to-risk ratio but may be considered for a trial in the above circumstances.

If quinine is prescribed, the recommended dose is 200–300 mg at bedtime for 4 weeks, with benefit monitored using a sleep and cramp diary. If no benefit is seen after 4 weeks, treatment should be stopped. If beneficial, continue for 3 months, then aim to stop treatment to reassess ongoing need. Further treatment should be reviewed every 3 months with consideration of trial discontinuation.

Advise the patient not to exceed the recommended dose due to risk of serious adverse effects, and to seek medical advice if signs of thrombocytopenia (e.g., unexplained bruising or bleeding) occur.