New Restless Leg Syndrome Guidance Reverses Some Previous Recommendations
A new clinical practice guideline from the American Academy of Sleep Medicine recommends significant changes in the treatment of patients with restless leg syndrome (RLS). The guideline, published in the Journal of Clinical Sleep Medicine, updates the academy’s previous guidance from 2012.
“This new clinical practice guideline … represents an important turning point in the treatment of RLS in adults,” said first author John Winkelman, MD, PhD, professor of psychiatry at Harvard Medical School and chief of the sleep disorders clinical research program at Massachusetts General Hospital, Boston, Massachusetts. “Guided by the best evidence in the scientific literature, we’ve provided recommendations that will improve the ability of clinicians to provide patient-centered care for people who have RLS.”
A significant guideline change emphasizes the need for iron evaluation and, if warranted, supplementation in patients. For adults with RLS, the guideline strongly recommends intravenous ferric carboxymaltose, and it conditionally recommends 2 other formulations of intravenous iron and 1 formulation of oral iron — ferrous sulfate. For children with RLS, the sole recommended treatment is ferrous sulfate, which received a conditional recommendation.
Strong recommendations should be followed under most circumstances, according to the authors. Conditional recommendations signal a lower degree of certainty and require clinicians to use their judgment.
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Another major change in the new guidance is conditional recommendations against the standard use of pramipexole and ropinirole. Although both had strong recommendations previously, more recent evidence suggests long-term use of the dopamine agonists, and other dopaminergic medications, is often associated with gradual worsening of RLS symptoms. Instead, new guidelines strongly recommend 3 alpha-2-delta ligand calcium channel blockers — gabapentin enacarbil, gabapentin, and pregabalin — which do not appear to be associated with gradual symptom worsening.
Other conditional recommendations in the guidance support bilateral high-frequency peroneal nerve stimulation, which involves the use of a wearable device to stimulate nerves in the legs before bedtime, and low-dose, extended-release oxycodone and other low-dose opioids.
However, “[t]he first step in the management of RLS should be addressing exacerbating factors,” the guidelines advised. “such as alcohol, caffeine, antihistaminergic, serotonergic, anti-dopaminergic medications, and untreated obstructive sleep apnea.”
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