Management of nocturnal muscle cramps resistant to initial preventive therapies in adults^*

* Initial preventative therapies should include stretching exercises and a thorough history, physical examination, and review of medications and laboratories to look for evidence of treatable risk factors.

¶ In older adults, vitamin K supplementation may also be a reasonable alternative. For more information, refer to UpToDate content on nocturnal muscle cramps.

Δ For each drug, the patient should start at the lowest recommended dose.

• The dose should be increased every 2 weeks towards the maximally tolerated dose, until the patient has an adequate clinical response.
• If a 2- to 4-week trial of the maximally tolerated dose is ineffective, the drug should be discontinued and the patient should advance to the next drug on the list.
• If the drug is partially beneficial, it can be added to the next drug on the list.

◊ Gabapentin must be used cautiously in older adults and patients with impaired kidney function. Refer to the drug monograph included within UpToDate for dose adjustments for kidney impairment.

§ Quinine is effective for reducing frequency and severity of nocturnal leg cramps; however, it is no longer routinely recommended due to the potential for serious side effects (eg, arrhythmias, thrombocytopenia). Tonic water contains quinine (approximately 15 mg per 180 mL) and may be used cautiously for patients with debilitating symptoms that do not respond to other interventions.