Abstract Introduction Restless leg syndrome (RLS) is characterized by an irresistible urge to move the limbs, triggered by rest and linked to dopaminergic dysfunction often related to low iron in the brain. RLS may coincide with obstructive sleep apnea (OSA), labeled as Co-ROSA, with a greater symptom burden. These disorders can worsen during hospitalization when overshadowed by acute conditions and medications. We present a hospitalized patient with Co-ROSA whose sleep disorders worsened during admission and affected recovery and adherence. Case Presentation A 77-year-old male with a history of alcohol abuse, colon and prostate cancer, OSA, and severe RLS was being followed in a sleep clinic. His RLS started in his 20s and he was treated with dopamine agonists for years, developing augmentation, with increasing doses of ropinirole up to 14 mg/day and a rotigotine transdermal patch 8 mg/24hr (above the FDA approved 4 mg and 3 mg, respectively). He required admission for a surgical repair of his quadriceps tendon and there was an attempt at that time to discontinue his ropinirole. He received tramadol 50-100 mg, acetaminophen-hydrocodone 325mg/5mg and morphine 2-4 mg as needed for pain. He had worsening RLS symptoms and post-surgical pain, so ropinirole was resumed up to 16 mg/day. After discharge, ropinirole was decreased and he was restarted on CPAP, gabapentin, suboxone and a tonic motor activation (TMA) device with improvement in his symptoms. However, he had colon cancer recurrence requiring an additional admission for a sigmoidectomy. During this admission, ropinirole was increased to 12 mg/day for worsening RLS symptoms and he was given opioids for pain. He is currently being followed in our sleep clinic with plans to replace ropinirole with gabapentin and opioids and perform a sleep study and resume CPAP treatment. Discussion Previous AASM guidelines recommended RLS treatment with ropinirole. Recent guidelines recommend against using dopamine agonists considering the risk of augmentation, which is the development of earlier and more severe RLS symptoms with a shorter medication effect and/or paradoxical response to dopamine agonist treatment. Immobility during hospitalization can exacerbate RLS and increasing the dose of ropinirole provides immediate, but short-term relief. Our patient received opioids which may induce central sleep apnea and worsen OSA. The resulting sleep deprivation can worsen RLS. This case highlights the complexity in managing patients with Co-ROSA and augmentation where hospitalization and disrupted sleep can further exacerbate symptoms, increase the use of opioids and impair recovery and treatment efficacy. This abstract is funded by: None
Tran et al. (Fri,) studied this question.