New guidelines from the American Academy of Sleep Medicine (AASM) for treatment of Restless Legs Syndrome (RLS) are here! Prior guidelines recommended RLS treatments that were effective in the short-term but often worsen RLS symptoms over the long-term. The good news is that there are RLS treatments that may provide safe and effective long-term solutions.
The 2012 AASM guidelines supported dopamine agonist drugs as the first line of treatment. Dopamine medications act enough like chemical messengers in your brain that they can activate the brain to lessen movement. They are also used to treat Parkinson’s Disease. These medications have worked well in quickly relieving symptoms of RLS, so well that providers were quick to prescribe them. What prescribers were not fully aware of at the time is that over time these medications often worsen RLS symptoms, called “augmentation.” The conclusion is that long-term risks outweigh the short-term benefits.
Augmentation
Augmentation is the term for the worsening of RLS symptoms caused by dopaminergic medications. After a few years of taking dopamine medications, patients may experience a worsening of RLS symptoms. There may be an earlier daytime onset of symptoms and shorter benefit at night, or symptoms may move from the legs to the arms. In response to this, doctors may increase the dose of the medication, which causes increased augmentation. Higher dosages lead to faster and more intense augmentation. As a result, many people with RLS are being prescribed doses of dopaminergic medications that exceed the maximum recommended for RLS by the Federal Drug Administration (FDA.)
Iron Deficiency
Research has linked two factors to RLS diagnosis: genetics and low iron in the brain. There is no treatment for genetics, but iron deficiency can be addressed. Low iron levels in the blood can indicate low iron levels in the brain. However, there may be brain iron deficiency even if there is no body/blood iron deficiency. If low iron is the case, an oral or IV iron supplement can make a big difference in RLS symptoms. Some patients may even be able to discontinue other RLS medications.
Gabapentin, Pregabalin, and Gabapentin Enacarbil Medications
These medications regulate brain and nerve activity. They are FDA-approved for pain associated with neuropathy (nerve damage causing nerve pain). They are also effective for RLS symptoms. They can have side effects, including sleepiness, unsteadiness, weight gain, and brain fog, but they do not cause or worsen RLS symptoms with long-term use.
Opioids
Low dose opioids can be a safe and effective treatment for RLS. The most commonly prescribed opioid for RLS is a very low dose of methadone (i.e., one-tenth of what is used for chronic pain). It doesn’t give the “high” of many opioids and thus carries a lower risk of being abused by RLS patients.
The new American Academy of Sleep Medicine clinical guidelines:
Strong for – recommended as a first line of treatment for RLS.
- Gabapentin
- Gabapentin enacarbil
- Pregabalin
- Intravenous ferric carboxymaltose – iron supplement
- Conditional for – recommended as a secondary treatment option.
- Intravenous LMW iron dextran – iron supplement
- Oral ferrous sulfate – iron supplement
- Dipyridamole
- Low dose opioids
- High frequency bilateral peroneal nerve stimulation – using an FDA-cleared device.
Conditional against – not a recommended treatment but may be useful for those people who value short-term benefits over longer-term risks of augmentation.
- Dopamine agonists – Consult with your doctor about the risks and benefits of dopamine agonists before treatment. This treatment often causes augmentation over time. Conditional against does not mean dopamine agonists can’t be prescribed or taken for RLS.
If you are taking dopamine agonist medication for RLS, see your doctor to discuss the benefits and risks of a change in treatment. It is possible to reduce and eliminate dopamine agonist medication while increasing other effective RLS treatments very slowly. This cannot be done quicky, as RLS worsens with reductions in dopamine medications. It is a process your doctor can manage and may pay off in the long term.
Dr. John Winkelman MD, PhD is a Professor of Psychiatry at Harvard Medical School and Chief of the Sleep Disorders Clinical Research Program in the Department of Psychiatry at Massachusetts General Hospital.