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nocturnal leg cramp

Etiology: 1) dehydration & electrolyte imbalance due to diuretics or laxatives 2) cancer 3) hemodialysis 4) pregnancy 5) idiopathic (most common) 6) myopathy or neuropathy may be accompanied by leg cramps 7) metobolic disorders - diabetes, hypoglycemia, hypothyroidism 8) alcoholism 9) pharmaceuticals a) beta adrenergic agonists b) angiotensin receptor blockers c) vasocontrictors d) chemotherapy with raloxifene, cisplatin or vincristine e) oral contraceptives f) levodopa, tricyclic antidepressants, bismuth salts ?? Epidemiology: - prevalence increases with age (30-70% of patients > 50 years) Clinical manifestations: - sudden nocturnal unilteral painful spasms of the gastrocnemius Laboratory: 1) serum K+ 2) serum Mg+2 3) serum Ca+2 4) also see muscle cramp Differential diagnosis: 1) contractures from myopathy 2) tetany 3) dystonia 4) myalgia 5) restless legs syndrome 6) intermittent claudication 7) compartment syndrome 8) peripheral neuropathy 9) peripheral vascular disease 10) nocturnal myoclonus Management: 1) quinine 260 mg PO QHS a) likely effective b) avoid routine use because of potential toxicity c) consider therapeutic trial after addressing potential toxicity [5] d) informed consent form [6] may be prudent 2) other agents have been tried without much success a) gabapentin b) verapamil 120 mg QHS c) diltiazem possibly of value [5] d) chloroquine 250 mg QD for 2-3 weeks, then 250-500 mg weekly [2] e) hydroxychloroquine 200 mg QD for 2 weeks, then weekly [2] f) muscle relaxants g) diphenhydramine 12.5-50 mg QHS h) vitamin E i) magnesium oxide of no benefit [8] j) B-vitamins possibly of value [5] k) vitamin K2 (menaquinone-4) 180 ug PO QD [1] 3) analgesics (acetaminophen, NSAIDs) may reduce pain, but do NOT stop the leg cramps 4) extension of gastrocnemius - extension at ankle (pull up at toes) 5) prevention a) stretch, ride stationary bike, or use a heating pad for a few minutes before bed b) adequate hydration c) ice massage d) regular aquatic exercise e) proper footwear 6) hemodialysis patients Shakuyaku-kanzo-to granule 2.5 g derived from peony root & licorice root [2,4]

Related

gastrocnemius quinine (Quinamm, Aflukin, Chinimetten, Qualaquin)

General

sleep-related movement disorder leg muscle cramp

References

  1. Prescriber's Letter 11(4):20 2004 Detail-Document#: 200410 (subscription needed) http://www.prescribersletter.com
  2. UpToDate 14.1 http://www.utdol.com
  3. Brunetti LL et al, Treatment of nocturnal leg cramps. Arch Intern Med 1994, 154:1037 PMID: 8179448
  4. Hyodo T et al, Immediate effect of Shakuyaku-kanzo-to on muscle cramp in hemodialysis patients, Nephron Clni Pract 2006, 104 PMID: 16685141
  5. Katzberg HD et al, Assessment: Symptomatic treatment for muscle cramps (an evidence-based review). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2010;74:691-696 PMID: 20177124 http://www.neurology.org/cgi/content/full/74/8/691
  6. Prescriber's Letter 17(6): 2010 COMMENTARY: How to Prevent Nighttime Leg Cramps DOCUMENT: SAMPLE Informed Consent Form for Quinine from Prescriber's Letter Detail-Document#: 260606 (subscription needed) http://www.prescribersletter.com
  7. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  8. Roguin Maor N, Alperin M, Shturman E et al. Effect of magnesium oxide supplementation on nocturnal leg cramps: A randomized clinical trial. JAMA Intern Med 2017 Feb 20 PMID: 28241153
  9. Tan J, Zhu R, Li Y, Wang L, Liao S, Cheng L, Mao L, Jing D. Vitamin K2 in managing nocturnal leg cramps: A randomized clinical trial. JAMA Intern Med 2024 Oct 28; [e-pub]. PMID: 39466236 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2825457