From the Guidelines
The initial workup and treatment of restless legs syndrome (RLS) should prioritize addressing underlying conditions, such as iron deficiency, and non-pharmacological approaches, with pharmacological treatment individualized based on symptom severity and patient preference, as recommended by the American Academy of Sleep Medicine 1. The initial workup for RLS should include a thorough clinical history focusing on the four essential diagnostic criteria: an urge to move the legs usually accompanied by uncomfortable sensations, symptoms that worsen during periods of rest or inactivity, partial or complete relief with movement, and symptoms that worsen in the evening or night.
Key Diagnostic Criteria
- An urge to move the legs usually accompanied by uncomfortable sensations
- Symptoms that worsen during periods of rest or inactivity
- Partial or complete relief with movement
- Symptoms that worsen in the evening or night Laboratory tests should include serum ferritin, iron, transferrin saturation, complete blood count, renal function, and glucose to identify secondary causes.
Laboratory Tests
- Serum ferritin
- Iron
- Transferrin saturation
- Complete blood count
- Renal function
- Glucose For treatment, first address any underlying conditions like iron deficiency (supplement if ferritin <75 ng/mL with oral iron 325 mg daily) 1.
Treatment Approach
- Address underlying conditions, such as iron deficiency
- Non-pharmacological approaches, including:
- Maintaining good sleep hygiene
- Regular exercise
- Avoiding caffeine and alcohol
- Leg massage
- Pharmacological treatment, individualized based on symptom severity and patient preference Non-pharmacological approaches include maintaining good sleep hygiene, regular exercise, avoiding caffeine and alcohol, and leg massage. For pharmacological treatment in moderate to severe cases, first-line medications include alpha-2-delta calcium channel ligands like pregabalin (strong recommendation, moderate certainty of evidence) 1. For intermittent symptoms, low-dose opioids like codeine or tramadol can be considered. Treatment should be individualized based on symptom severity, comorbidities, and patient preference, with regular follow-up to monitor efficacy and side effects.
Pharmacological Treatment Options
- Alpha-2-delta calcium channel ligands, such as pregabalin
- Low-dose opioids, such as codeine or tramadol It is essential to note that the American Academy of Sleep Medicine suggests against the standard use of certain medications, including levodopa, pramipexole, ropinirole, and cabergoline, due to concerns about augmentation and other adverse effects 1.
Medications to Avoid
- Levodopa
- Pramipexole
- Ropinirole
- Cabergoline Overall, the treatment of RLS should prioritize a comprehensive approach, addressing underlying conditions, and individualizing pharmacological treatment based on symptom severity and patient preference, while minimizing the risk of adverse effects.
From the FDA Drug Label
The effectiveness of ropinirole in the treatment of RLS was demonstrated in randomized, double-blind, placebo-controlled trials in adults diagnosed with RLS using the International Restless Legs Syndrome Study Group diagnostic criteria Patients were required to have a history of a minimum of 15 RLS episodes/month during the previous month and a total score of ≥15 on the International RLS Rating Scale (IRLS scale) at baseline. All trials employed flexible dosing, with patients initiating therapy at 0.25 mg ropinirole once daily. Patients were titrated based on clinical response and tolerability over 7 weeks to a maximum of 4 mg once daily.
The initial workup and treatment of restless legs syndrome (RLS) involves:
- Diagnosing RLS using the International Restless Legs Syndrome Study Group diagnostic criteria
- Assessing the severity of symptoms using the International RLS Rating Scale (IRLS scale)
- Initiating therapy with ropinirole at a dose of 0.25 mg once daily, taken between 1 and 3 hours before bedtime
- Titration of the dose based on clinical response and tolerability over 7 weeks to a maximum of 4 mg once daily 2, 2 Key points:
- Patients should have a history of at least 15 RLS episodes/month and a total score of ≥15 on the IRLS scale at baseline
- The treatment goal is to reduce the severity of symptoms and improve quality of life
- Long-term maintenance of efficacy in the treatment of RLS was demonstrated in a 36-week trial 2
From the Research
Initial Workup of Restless Legs Syndrome
- The initial workup of restless legs syndrome (RLS) begins with a thorough history and examination, including iron measures such as ferritin and transferrin saturation 3
- Evaluation of iron stores is crucial, as iron deficiency is a common cause of secondary RLS 3, 4
- A family history of RLS should also be obtained, as genetic predisposition is common 3
Treatment of Restless Legs Syndrome
- First-line management options for RLS include iron-replacement therapy, gabapentin, pregabalin, and dopamine agonists such as pramipexole, ropinirole, and rotigotine 3, 5
- Non-pharmacological measures such as massage, temperate baths, and regular physical activity may also be beneficial for some patients 6, 7
- Second-line therapies include intravenous iron infusion and opioids such as tramadol, oxycodone, and methadone 3
- Alternative treatments such as mind-body interventions, lifestyle interventions, and neutraceuticals may also be considered, although evidence for their effectiveness is limited 6, 7
Non-Pharmacological Interventions
- Repetitive transcranial magnetic stimulation, exercise, compression devices, counterstrain manipulation, infrared therapy, and standard acupuncture may be effective in reducing RLS severity 7
- Vibration pads, cryotherapy, yoga, compression devices, and acupuncture may improve sleep-related outcomes in RLS patients 7
- Good sleep hygiene and avoidance of alcohol, caffeine, and nicotine may also improve symptoms 4