From the Guidelines
The most effective treatment for restless leg syndrome (RLS) is the use of gabapentin enacarbil, as recommended by the American Academy of Sleep Medicine (AASM) with a strong recommendation and moderate certainty of evidence 1.
Treatment Options for RLS
The treatment of RLS involves both non-medication and medication approaches. Non-medication strategies should be tried first, including:
- Regular exercise
- Maintaining good sleep habits
- Avoiding caffeine and alcohol
- Applying heat or cold to the legs Iron supplementation is recommended for patients with low ferritin levels (below 75 ng/mL) 1.
Medication Treatment
For medication treatment, the AASM suggests the use of:
- Ferrous sulfate over no ferrous sulfate in patients with appropriate iron status 1
- Dipyridamole over no dipyridamole 1
- Extended-release oxycodone and other opioids over no opioids 1
- Bilateral high-frequency peroneal nerve stimulation over no peroneal nerve stimulation 1 However, the AASM suggests against the standard use of:
- Levodopa 1
- Pramipexole 1
- Transdermal rotigotine 1
- Ropinirole 1
- Bupropion 1
- Carbamazepine 1
- Clonazepam 1
- Valproic acid 1
- Cabergoline 1
Special Populations
In special populations of adults with RLS, such as those with end-stage renal disease (ESRD), the AASM suggests the use of:
Pediatric RLS Treatment
In pediatric RLS treatment, the evidence points to the use of oral iron supplementation in cases of iron deficiency as a low-risk, accessible treatment that may address an underlying cause of the condition 1.
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.
Treatment Options for Restless Leg Syndrome (RLS):
- Ropinirole: The medication has been shown to be effective in the treatment of RLS, with a significant reduction in symptoms compared to placebo 2 2.
- Dosage: The recommended dosage is 0.25 mg once daily, titrated up to a maximum of 4 mg once daily based on clinical response and tolerability.
- Administration: All doses should be taken between 1 and 3 hours before bedtime.
- Efficacy: Ropinirole has been demonstrated to have long-term maintenance of efficacy in the treatment of RLS, with a significantly lower relapse rate compared to placebo 2.
From the Research
Treatment Options for Restless Leg Syndrome (RLS)
The treatment options for RLS can be categorized into pharmacological and non-pharmacological approaches.
- Pharmacological treatment should be limited to patients who suffer from clinically relevant RLS, where symptoms impair the patient's quality of life, daytime functioning, social functioning, or sleep 3.
- Treatment on demand is a clinical need in some RLS patients, and medications include carbidopa/levodopa, pramipexole, ropinirole, oxycodone, methadone, codeine, and tramadol 3.
Pharmacological Treatment
- Dopaminergic agents, such as pramipexole and ropinirole, are considered first-line treatment for RLS 4, 5.
- Chronic RLS should be treated with either a nonergot dopamine agonist or an α-2-δ calcium channel ligand 3.
- α-2-δ ligands can alleviate chronic pain and may be helpful in treating anxiety and insomnia, making them a suitable choice for patients with these comorbidities 3.
- For RLS present throughout the day and night, the use of long-acting agents, such as the rotigotine patch or gabapentin enacarbil, should be considered 3.
- In refractory RLS, oral prolonged release oxycodone-naloxone should be considered 3, 6, 7.
Non-Pharmacological Treatment
- Non-pharmacological therapy may be suitable for patients with milder symptoms that occur intermittently 7.
- Maintaining a high serum ferritin level may help prevent the development of augmentation, a common side effect of dopamine agonists 7.
Emerging Trends in RLS Treatment
- Gabapentinoid agents, such as gabapentin enacarbil and pregabalin, have shown comparable short-term efficacy to dopaminergics with a lower risk of augmentation 6.
- Iron supplementation therapy, including treatment with ferric carboxymaltose, may be beneficial for patients with low iron stores 6.
- Opioids, such as oxycodone-naloxone, can be effective for severe cases of RLS and may be considered for patients who have failed other therapies 6, 7.