# Restless Legs Syndrome (Willis-Ekbom disease) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: IRLSSG Consensus Guidelines on Restless Legs Syndrome 2016 · Egyptian National Drug Formulary, nervous system 2025, pramipexole monograph, restless legs syndrome (printed p. 88) · Ropinirole tablets, film coated (Bionpharma Inc.) US prescribing information, section 1.2 Restless Legs Syndrome, section 2.3 Dosing for Restless Legs Syndrome and section 5 Warnings and Precautions (DailyMed SetID 4e6b070c-50a6-4742-af3c-59b45c45735e) · NEUPRO (rotigotine) transdermal system US prescribing information, section 1.2 Restless Legs Syndrome, section 2.2 Dosage in Restless Legs Syndrome and section 5 Warnings and Precautions (DailyMed SetID 939e28c5-f3a9-42c0-9a2d-8d471d82a6e0) · Restless Legs Syndrome - StatPearls - NCBI Bookshelf (NBK430878) - the article states the dose for this use - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary, nervous system 2025, pramipexole monograph, restless legs syndrome (printed p. 88) - IRLSSG Consensus Guidelines on Restless Legs Syndrome 2016 - Restless Legs Syndrome - disease-level clinical article (restless-legs-syndrome-full.txt) - Ropinirole tablets, film coated (Bionpharma Inc.) US prescribing information, section 1.2 Restless Legs Syndrome, section 2.3 Dosing for Restless Legs Syndrome and section 5 Warnings and Precautions (DailyMed SetID 4e6b070c-50a6-4742-af3c-59b45c45735e) - NEUPRO (rotigotine) transdermal system US prescribing information, section 1.2 Restless Legs Syndrome, section 2.2 Dosage in Restless Legs Syndrome and section 5 Warnings and Precautions (DailyMed SetID 939e28c5-f3a9-42c0-9a2d-8d471d82a6e0) ## Treatment metadata - Pramipexol — 0.18 mg — oral.solid - Referral & safety-netting (no drug therapy) - Ropinirole — oral.solid - Rotigotine — topical - Ferrous fumarate — 200 mg — oral.solid - Ascorbic acid — oral.solid ## Complete treatment card ```text RESTLESS LEGS SYNDROME (WILLIS-EKBOM DISEASE) Sources: IRLSSG Consensus Guidelines on Restless Legs Syndrome 2016 · Egyptian National Drug Formulary, nervous system 2025, pramipexole monograph, restless legs syndrome (printed p. 88) · Ropinirole tablets, film coated (Bionpharma Inc.) US prescribing information, section 1.2 Restless Legs Syndrome, section 2.3 Dosing for Restless Legs Syndrome and section 5 Warnings and Precautions (DailyMed SetID 4e6b070c-50a6-4742-af3c-59b45c45735e) · NEUPRO (rotigotine) transdermal system US prescribing information, section 1.2 Restless Legs Syndrome, section 2.2 Dosage in Restless Legs Syndrome and section 5 Warnings and Precautions (DailyMed SetID 939e28c5-f3a9-42c0-9a2d-8d471d82a6e0) · Restless Legs Syndrome - StatPearls - NCBI Bookshelf (NBK430878) - the article states the dose for this use Review status: REVIEWED against Egyptian National Drug Formulary, nervous system 2025, pramipexole monograph, restless legs syndrome (printed p. 88), IRLSSG Consensus Guidelines on Restless Legs Syndrome 2016, Restless Legs Syndrome - disease-level clinical article (restless-legs-syndrome-full.txt), Ropinirole tablets, film coated (Bionpharma Inc.) US prescribing information, section 1.2 Restless Legs Syndrome, section 2.3 Dosing for Restless Legs Syndrome and section 5 Warnings and Precautions (DailyMed SetID 4e6b070c-50a6-4742-af3c-59b45c45735e), NEUPRO (rotigotine) transdermal system US prescribing information, section 1.2 Restless Legs Syndrome, section 2.2 Dosage in Restless Legs Syndrome and section 5 Warnings and Precautions (DailyMed SetID 939e28c5-f3a9-42c0-9a2d-8d471d82a6e0) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (6) - Patients describe a deep crawling, creeping, pulling, itching, or stretching feeling in the legs rather than something on the skin surface. [itching] - True neuropathic pain or tingling, and sensitivity of the skin to touch, are both notably absent. - Symptoms are worst in the evening and typically start within 15 to 30 minutes of getting into bed at night. - In more severe disease, symptoms can begin earlier in the day while seated, interfering with meetings or a movie. - Walking or stretching partly or fully relieves the urge to move, and symptoms stay quiet as long as the activity continues. - Because symptoms peak in the evening and disrupt sleep, patients frequently end up tired the following day. [fatigue] SIGNS - what you find (2) - The physical exam is generally normal and is mainly done to look for a secondary cause. - Periodic leg movements during sleep - a forceful upward foot flex lasting half a second to five seconds, recurring every 20 to 40 seconds - occur in most patients. TESTS (6) - There's no test that diagnoses RLS itself - testing is only used to exclude secondary causes. - If a full iron panel isn't feasible, checking ferritin alone is the acceptable minimum. - If a patient's previously controlled symptoms return or worsen (augmentation), iron status should be rechecked. - Augmentation shows up as symptoms starting earlier in the evening, feeling worse in the morning, or spreading to the arms and upper body. - Polysomnography can quantify how often the legs move and characterize the overall sleep pattern. - Nerve conduction studies and EMG are worth considering when radiculopathy or neuropathy seems likely clinically, even with a normal neuro exam. IF NOT THIS - what else fits (2) - Tardive dyskinesia, akathisia, and ordinary leg cramps are considered in the differential for RLS. - Vascular disease, muscle spasms, and radiculopathy are also weighed when distinguishing RLS from other causes. Source StatPearls "Restless Legs Syndrome" - disease-level clinical article Status traced to the source above Rx: Main treatment | Dopamine agonist alternative to pramipexole - immediate-release tablet at bedtime | Transdermal dopamine agonist - 24-hour delivery where symptoms are not confined to the evening | Taken with the iron tablet to improve iron absorption MAIN TREATMENT - choose one, plus any add-on marked below 1. PRAMIPEXOL [1st line] Adult 0.088-0.18 mg once daily 2-3 hours before bedtime - long-term Peds Age restriction: minimum 216 months (Specialist paediatric neurology consultation required) Source Egyptian National Drug Formulary, nervous system 2025, pramipexole monograph, restless legs syndrome (printed p. 88) Why Pramipexole is a dopamine agonist that corrects the dopaminergic dysfunction thought to underlie restless legs syndrome, easing the urge to move the legs and the associated discomfort, particularly in the evening. Caution Doses are expressed as free base (0.088 mg base = 0.125 mg salt). There is a risk of impulse control disorders (gambling, hypersexuality, binge eating). Titration, if 0.088 mg is not enough: step up every 4-7 days through 0.18, then 0.35, then 0.54 mg once daily. 0.54 mg is the ceiling for restless legs - do not carry on to Parkinson's doses. Review at three months whether it is still needed. If it is stopped for more than a few days, titrate again from the start rather than resuming the old dose. Below 0.54 mg a day it can be stopped outright. No renal adjustment above a clearance of 20 mL/min; below that, and on dialysis, it has not been studied. There is a risk of symptom augmentation with prolonged high-dose use. Egypt SIFROL 0.18MG 30 TAB. BOEHRINGER IN... 150.00 EGP (5.00/unit) 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Restless Legs Syndrome - disease-level clinical article (restless-legs-syndrome- full.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Augmentation (symptoms worsening/spreading with earlier onset) is a recognized complication of prolonged dopamine agonist use, including the pramipexole listed here, and should prompt reassessment rather than simple continuation. 3. FERROUS FUMARATE [add-on - not a substitute] Adult 200 mg 1-2 times daily if serum ferritin <= 75 mcg/L x 3 months Peds 3-6 mg/kg/day [child max 180 mg] (Divided into 2 doses daily; elemental iron basis. Ceiling of 180 mg is the formulary maximum for a child: 20 mL/day of the 140 mg/5 mL syrup, which is 45 mg elemental iron per 5 mL. This is deliberately above the 130 mg an adult gets here: a growing child needs more elemental iron per kilogram, and modern adult practice is lower and less frequent dosing than the formulary allows. It is not an inversion to correct.) 3kg -> 9-18 mg/day 4kg -> 12-24 mg/day 5kg -> 15-30 mg/day 6kg -> 18-36 mg/day 7kg -> 21-42 mg/day 8kg -> 24-48 mg/day 9kg -> 27-54 mg/day 10kg -> 30-60 mg/day 11kg -> 33-66 mg/day 12kg -> 36-72 mg/day 13kg -> 39-78 mg/day 14kg -> 42-84 mg/day 15kg -> 45-90 mg/day 16kg -> 48-96 mg/day 17kg -> 51-102 mg/day 18kg -> 54-108 mg/day 19kg -> 57-114 mg/day 20kg -> 60-120 mg/day 21kg -> 63-126 mg/day 22kg -> 66-132 mg/day 23kg -> 69-138 mg/day 24kg -> 72-144 mg/day 25kg -> 75-150 mg/day 26kg -> 78-156 mg/day 27kg -> 81-162 mg/day 28kg -> 84-168 mg/day 29kg -> 87-174 mg/day 30kg -> 90-180 mg/day 31kg -> 93-180 mg/day (upper capped) 32kg -> 96-180 mg/day (upper capped) 33kg -> 99-180 mg/day (upper capped) 34kg -> 102-180 mg/day (upper capped) 35kg -> 105-180 mg/day (upper capped) 36kg -> 108-180 mg/day (upper capped) 37kg -> 111-180 mg/day (upper capped) 38kg -> 114-180 mg/day (upper capped) 39kg -> 117-180 mg/day (upper capped) 40kg -> 120-180 mg/day (upper capped) 41kg -> 123-180 mg/day (upper capped) 42kg -> 126-180 mg/day (upper capped) 43kg -> 129-180 mg/day (upper capped) 44kg -> 132-180 mg/day (upper capped) 45kg -> 135-180 mg/day (upper capped) 46kg -> 138-180 mg/day (upper capped) 47kg -> 141-180 mg/day (upper capped) 48kg -> 144-180 mg/day (upper capped) 49kg -> 147-180 mg/day (upper capped) 50kg -> 150-180 mg/day (upper capped) Source IRLSSG Consensus Guidelines on Restless Legs Syndrome 2016 Why Iron replacement is disease-modifying in restless legs when ferritin is low, not just supportive. Egypt sells ferrous fumarate rather than the sulphate the guideline names; match the elemental iron, not the tablet weight. Caution Check serum ferritin in all RLS patients; supplement if ferritin <= 75 mcg/L. Iron deficiency in central nervous system exacerbates RLS symptoms. Take on an empty stomach with Vitamin C for optimal absorption. Most iron tablets in Egypt come with folic acid in them, though not all - check the pack. Folate corrects the blood picture of B12 deficiency while the neurological damage carries on - check B12 before starting if the anaemia is macrocytic, mixed, or unexplained. The guideline says ferrous sulphate. The Egyptian formulary has no ferrous sulphate monograph; its oral iron is ferrous fumarate, 200 mg tablet = 65.57 mg elemental. Substitute on elemental iron, not on tablet weight. The pack a pharmacy hands over is a combination rather than plain iron - besides folic acid, many Egyptian iron products add vitamin C, and some add zinc or B vitamins. A combination is an acceptable way to give oral iron: the formulary's ferrous fumarate monograph lists the dosage forms as a 200 mg tablet and a 140 mg/5 mL syrup, then adds combination products to that list, and states the adult dose in elemental iron (100 to 200 mg elemental iron daily). The vitamin C is wanted rather than merely tolerated - 200 to 500 mg alongside oral iron is recommended to enhance its absorption. Dose by the elemental iron the pack states, not by tablet weight and not by the other ingredients. The Egyptian register does not record elemental iron content for most of these products, so the carton has to be read. Egypt FERROL 10 F.C. TABLET AMOUN 2.00 EGP (0.20/unit) -> ! also contains folic acid FOLIFER 30 TAB. MISR 7.20 EGP (0.24/unit) -> ! also contains folic acid FERROZINC-C 24 CAPS. SAFE PHARMA >... 7.50 EGP (0.31/unit) -> ! also contains vitamin c, zinc IROFOL 30 CAPS. MULTICARE 40.50 EGP (1.35/unit) -> ! also contains copper, folic acid, pyridoxine, vitamin b12, zinc HAEMACTIN 30 CAPS. DELTA GRAND P... 150.00 EGP (5.00/unit) -> ! also contains folic acid, vitamin b12 TESLAGLOBIN 20 CAP DAWA EGYPT IN... 140.00 EGP (7.00/unit) -> ! also contains b12, b6, copper, folic acid, zinc CHEMARED CAPSULE PHARMA ZAD > ... 195.00 EGP -> ! also contains calcium, methyl cobolamine, pyridoxine FERRONIL 125MG/5ML SYRUP 120 ML EL NILE. 4.00 EGP -> ? strength differs, ? different route - not oral solid DOPAMINE AGONIST ALTERNATIVE TO PRAMIPEXOLE - IMMEDIATE-RELEASE TABLET AT BEDTIME 4. ROPINIROLE [1st line] Adult Started very low and titrated weekly, taken before bed. US label verbatim: "The recommended adult starting dose for RLS is 0.25 mg once daily 1 to 3 hours before bedtime. After 2 days, if necessary, the dose can be increased to 0.5 mg once daily, and to 1 mg once daily at the end of the first week of dosing, then as shown in Table 2 as needed to achieve efficacy. Titration should be based on individual patient therapeutic response and tolerability, up to a maximum recommended dose of 4 mg daily. For RLS, the safety and effectiveness of doses greater than 4 mg once daily have not been established." The label's own schedule is 0.25 mg on days 1 to 2, 0.5 mg on days 3 to 7, then 1 mg, 1.5 mg, 2 mg, 2.5 mg, 3 mg and 4 mg at weeks 2 to 7. On dialysis it starts at 0.25 mg once daily with a 3 mg daily ceiling. - Continued while it helps and reviewed for augmentation, then withdrawn slowly. US label verbatim: "When discontinuing ropinirole in patients with RLS, gradual reduction of the daily dose is recommended." Peds Not a paediatric prescription. US label verbatim: "Safety and effectiveness in pediatric patients have not been established." Restless legs in a child is usually iron deficiency until proven otherwise, and the ferrous fumarate row on this card is the relevant one. Source Ropinirole tablets, film coated (Bionpharma Inc.) US prescribing information, section 1.2 Restless Legs Syndrome, section 2.3 Dosing for Restless Legs Syndrome and section 5 Warnings and Precautions (DailyMed SetID 4e6b070c-50a6-4742-af3c-59b45c45735e) Why The disease article names the drug inside the class it recommends, verbatim: "Dopamine agonists, including pramipexole, ropinirole, rotigotine, and cabergoline, have reduced symptoms and improved sleep quality and quality of life." and adds the honest caveat that belongs beside it - "Pramipexole and ropinirole have adverse effects, including gambling addiction and extreme weight gain." The US label's indication section names the disease, verbatim: "Ropinirole tablets are indicated for the treatment of moderate-to- severe primary Restless Legs Syndrome (RLS)." The card carried pramipexole alone, and the article's own meta-analysis sentence compares the two directly, so a patient who cannot tolerate one had nothing to move to. Ropinirole is cheap in Egypt - ROPINIROLE 0.25 mg tablets are on the register at 5.5 EGP - which matters for a drug taken every night. Caution The characteristic failure of this drug class is that it makes the disease worse over time. Ropinirole label verbatim: "Augmentation is a phenomenon in which dopaminergic medication causes a worsening of symptom severity above and beyond the level at the time the medication was started. The symptoms of augmentation may include the earlier onset of symptoms in the evening (or even the afternoon), increase in symptoms, and spread of symptoms to involve other extremities." and "If augmentation or early-morning rebound occurs, the use of ropinirole should be reviewed and dosage adjustment or discontinuation of treatment should be considered." A patient whose legs now trouble them in the afternoon is not under-treated - escalating the dose is the wrong move. RED FLAG - sudden sleep attacks while driving. US label section 5.1 is titled "Falling Asleep during Activities of Daily Living and Somnolence". Ask directly about drowsiness at follow-up; the label's own point is that patients may not report it unless asked. Impulse control disorders are a named class effect and patients do not volunteer them. The disease article puts it plainly: ropinirole has "adverse effects, including gambling addiction and extreme weight gain." Ask about gambling, spending, eating and sexual behaviour at every review, and ask the family too. Postural hypotension and syncope during titration - the label carries separate warnings for both. Take a lying and standing blood pressure at the start and at each dose step, especially in an older patient. Hallucinations and psychotic-like behaviour are listed warnings. New confusion or visual hallucinations after a dose increase is the drug until proved otherwise. Correct the iron first. The article's own list of things that alleviate symptoms begins with "iron replacement", and the ferrous fumarate row on this card exists for that reason. Starting a dopamine agonist over an untreated iron deficiency treats the symptom and leaves the cause. Egypt ROPINIROLE 0.25 MG 10 TAB. EPCI 5.50 EGP (0.55/unit) ROPINIROLE 0.5 MG 30 TAB. EPCI 27.00 EGP (0.90/unit) TREMODECT 1 MG 30 F.C.TABS. EVA PHARMA 31.50 EGP (1.05/unit) ROPINIROLE 2 MG 10 TAB. EPCI 12.00 EGP (1.20/unit) TREMODECT 4 MG 30 F.C. TABS. EVA PHARMA 52.50 EGP (1.75/unit) TRANSDERMAL DOPAMINE AGONIST - 24-HOUR DELIVERY WHERE SYMPTOMS ARE NOT CONFINED TO THE EVENING 5. ROTIGOTINE [2nd line] Adult One patch a day, titrated weekly. US label verbatim: "In patients with Restless Legs Syndrome, the recommended starting dose for NEUPRO is 1 mg/24 hours. Based upon individual patient clinical response and tolerability, NEUPRO dosage may be increased weekly by 1 mg/24 hours if additional therapeutic effect is needed. The lowest effective dose is 1 mg/24 hours. The maximum recommended dose is 3 mg/24 hours." - Continued while it helps, and stepped down rather than stopped. US label verbatim: "For discontinuation of NEUPRO in patients with Restless Legs Syndrome, reduce the daily dose by 1 mg every 24 hours preferably every other day, until complete withdrawal of NEUPRO is achieved." Peds Not a paediatric prescription; the label establishes no paediatric use in this indication. Source NEUPRO (rotigotine) transdermal system US prescribing information, section 1.2 Restless Legs Syndrome, section 2.2 Dosage in Restless Legs Syndrome and section 5 Warnings and Precautions (DailyMed SetID 939e28c5-f3a9-42c0-9a2d-8d471d82a6e0) Why The disease article names the drug twice, once in the class and once as a formulation, verbatim: "Dopamine agonists, including pramipexole, ropinirole, rotigotine, and cabergoline, have reduced symptoms and improved sleep quality and quality of life." and "The rotigotine transdermal patch can also be used. It is well tolerated and has a relatively low risk of clinically significant augmentation of RLS." The US label's indication section names the disease, verbatim: "NEUPRO is indicated for the treatment of moderate-to-severe primary Restless Legs Syndrome." It earns a separate row from the oral agonists because the article's reason for it is a property of the patch rather than of the molecule - steady 24-hour delivery, and less augmentation. Egypt registers no rotigotine product, so no brand and no price can be shown. Caution RED FLAG - sudden sleep attacks while driving. US label verbatim: "Patients with early- and advanced-stage Parkinson's disease and with Restless Legs Syndrome treated with NEUPRO have reported falling asleep while engaged in activities of daily living, including the operation of motor vehicles, which sometimes resulted in accidents. Although many of these patients reported somnolence while on NEUPRO, some did not perceive warning signs, such as excessive drowsiness, and believed that they were alert immediately prior to the event. Some of these events have been reported as late as one year after initiation of treatment." At the maximum 3 mg/24 hours dose, 2% of restless- legs patients reported sleep attacks against 0% on placebo. It moves the blood pressure in both directions. US label verbatim: "An increased risk for decreases in systolic and diastolic blood pressure were observed when supine, standing, and changing from supine to standing position in patients treated with NEUPRO." and, separately, "In patients with Restless Legs Syndrome, this increased risk for diastolic blood pressure greater than 105 mm Hg was 8% for NEUPRO and 4% for placebo." New or worsening psychiatric symptoms. US label verbatim: "Post-marketing reports indicate that patients with Parkinson's disease or RLS may experience new or worsening mental status and behavioral changes, which may be severe, including psychotic behavior during NEUPRO treatment or after starting or increasing the dose of NEUPRO." Augmentation is less likely with the patch but is not excluded. The disease article's wording is careful - it has "a relatively low risk of clinically significant augmentation", not none. Evening-shifted or spreading symptoms are still a reason to review rather than to increase. Somnolence is common enough to be part of the conversation. US label verbatim: "Somnolence is a common occurrence in patients receiving NEUPRO." For restless legs at the maximum dose it was 10% against 4% on placebo. No Egyptian product exists, so the patch cannot be filled at a pharmacy in Cairo. It is printed so that one brought in from abroad can be recognised, dosed and withdrawn correctly rather than guessed at. Egypt no Egyptian brand matched - prescribe by generic name TAKEN WITH THE IRON TABLET TO IMPROVE IRON ABSORPTION - give alongside 6. ASCORBIC ACID [add-on - not a substitute] Adult 250 mg taken at the same time as the iron tablet Peds No paediatric dose in the sources opened. Source Restless Legs Syndrome - StatPearls - NCBI Bookshelf (NBK430878) - the article states the dose for this use Why The card already replaces iron but says nothing about how to make it work. The article pairs the iron tablet with vitamin C on an empty stomach, which is the difference between replacement and no replacement. Caution Give it with the iron on an empty stomach and eat nothing for an hour afterwards, or the absorption gain is lost. This is an absorption aid, not a treatment for restless legs on its own. Egypt C-VITON 500 MG 20 TABS KAHIRA 8.00 EGP (0.40/unit) CEVAROL 500MG 20 TAB. MEMPHIS 12.00 EGP (0.60/unit) C-SAFE 500 MG 36 CAPS. SAFE PHARMA 35.00 EGP (0.97/unit) MUNITO C 1000 MG 60 F.C. TABS. MULTICARE 156.50 EGP (2.61/unit) VITAMIN C 500 MG 30 TABS. (NEW BOSTON) COPAD > NEW BOSTON PH... 120.00 EGP (4.00/unit) VITACID C 1 GM 12 EFF. TAB. CID 54.00 EGP ADVANCED VITAMIN C 30 GUMMIES VITACARE > VI... 599.00 EGP VITAMIN C 1000 MG 100 CAPLETS (PURITANS PRIDE) PURITANS PRIDE > ARAB IMP... 850.00 EGP CEBION 100MG/ML ORAL DROPS 30 ML AMOUN > MERCK... 5.50 EGP -> ? strength differs, ? different route - not oral solid UR-C ORAL DROPS 15 ML HI-PHARM 6.00 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)