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
Treatment options for restless leg syndrome include both non-medication and medication approaches. For mild cases, lifestyle modifications are recommended first:
- regular exercise
- maintaining good sleep habits
- avoiding caffeine and alcohol
- applying heat or cold to the legs. Iron supplements (typically ferrous sulfate 325 mg daily) are advised for those with low ferritin levels below 75 ng/mL.
Medication Approaches
For moderate to severe symptoms, medications include:
- dopamine agonists like pramipexole (0.125-0.5 mg) or ropinirole (0.25-4 mg) taken 1-3 hours before bedtime
- alpha-2-delta calcium channel ligands such as gabapentin (300-1200 mg daily) or pregabalin (75-300 mg daily)
- low-dose opioids like oxycodone or tramadol may be considered for severe cases
- bilateral high-frequency peroneal nerve stimulation is a new noninvasive nonpharmacological treatment that receives a conditional recommendation from initial success in short-term sham-controlled studies and a longer observational extension 1.
Special Considerations
It's essential to note that dopamine medications can cause augmentation (worsening symptoms) with long-term use, so treatment should be monitored regularly. Addressing underlying conditions like iron deficiency, diabetes, or kidney disease is also crucial as these can exacerbate symptoms. The AASM suggests against the standard use of levodopa, pramipexole, transdermal rotigotine, and ropinirole due to the risk of augmentation with long-term use, but these medications may be considered in patients who place a higher value on the reduction of restless legs symptoms with short-term use and a lower value on adverse effects with long-term use 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.
The treatment options for Restless Leg Syndrome (RLS) include ropinirole, which has been shown to be effective in reducing symptoms of RLS. The recommended dosage is to start with 0.25 mg once daily and titrate up to a maximum of 4 mg once daily, taken 1-3 hours before bedtime. Key benefits of ropinirole include:
- Significant reduction in RLS symptoms, as measured by the International RLS Rating Scale (IRLS scale)
- Improvement in sleep disturbance and daytime somnolence
- Long-term maintenance of efficacy in the treatment of RLS, as demonstrated in a 36-week trial 2 2
From the Research
Treatment Options for Restless Leg Syndrome
The treatment options for restless leg syndrome (RLS) can be categorized into non-pharmacological interventions and pharmacological treatments.
- Non-pharmacological interventions:
- Pharmacological treatments:
- Dopaminergic agents, such as pramipexole, ropinirole, and rotigotine transdermal patch, are considered first-line treatments for RLS 4, 5
- α2δ anticonvulsants, such as gabapentin and pregabalin, may also be considered as drugs of choice for moderate to severe RLS patients 5, 6
- Opioids, such as codeine, tramadol, and oxycodone, should be considered for RLS patients, especially for those who have failed other therapies 4, 5, 6
- Benzodiazepines, such as clonazepam and nitrazepam, may be used to improve sleep quality in patients with RLS, but their therapeutic effects on RLS symptoms are modest 3
Considerations for Treatment
When selecting a treatment for RLS, the following factors should be considered:
- Severity of symptoms: Patients with moderate to severe RLS typically require daily medication to control their symptoms 6
- Presence of comorbidities: The presence of depression, anxiety, or insomnia may favor the use of certain medications, such as α2δ anticonvulsants or benzodiazepines 4, 3
- Risk of augmentation: Dopaminergic agents can cause augmentation, a paradoxical worsening of symptoms, and strategies to prevent augmentation should be considered, such as keeping the dose as low as possible and using longer-acting agents 5, 6
- Iron deficiency: Iron deficiency should be identified and treated, as it may improve RLS symptoms and reduce the risk of augmentation 5