From the Guidelines
Managing Restless Legs Syndrome (RLS) involves both non-pharmacological and pharmacological approaches, with the American Academy of Sleep Medicine (AASM) suggesting the use of ferrous sulfate over no ferrous sulfate in patients with appropriate iron status 1. For mild RLS, lifestyle modifications should be tried first, including regular exercise, maintaining good sleep hygiene, avoiding caffeine, alcohol, and nicotine, and practicing relaxation techniques.
- Iron supplementation is recommended for patients with ferritin levels below 75 ng/mL, typically with ferrous sulfate 325 mg taken with vitamin C to enhance absorption.
- For moderate to severe RLS requiring medication, the AASM suggests against the standard use of levodopa, pramipexole, ropinirole, and transdermal rotigotine, due to the risk of augmentation 1.
- The AASM recommends the use of gabapentin enacarbil over no gabapentin enacarbil (strong recommendation, moderate certainty of evidence) 1.
- Alpha-2-delta calcium channel ligands like gabapentin (300-1200 mg daily) or pregabalin (75-300 mg daily) are also effective options, particularly for patients with pain or anxiety.
- For refractory cases, low-dose opioids such as oxycodone or methadone may be considered, with the AASM suggesting the use of extended-release oxycodone and other opioids over no opioids (conditional recommendation, moderate certainty of evidence) 1.
- It's essential to address potential triggers like certain medications (antidepressants, antihistamines, antipsychotics) and underlying conditions (iron deficiency, kidney disease, diabetes, pregnancy).
- Regular reassessment is necessary as augmentation (symptom worsening) can occur with dopaminergic medications.
- Treatment should be individualized based on symptom severity, comorbidities, and patient preferences, as RLS is a chronic condition requiring ongoing management.
From the FDA Drug Label
2.3 Dosing for Restless Legs Syndrome The recommended adult starting dose for RLS is 0.25 mg once daily 1 to 3 hours before bedtime. After 2 days, if necessary, the dose can be increased to 0.5 mg once daily, and to 1 mg once daily at the end of the first week of dosing, then as shown in Table 2 as needed to achieve efficacy. Titration should be based on individual patient therapeutic response and tolerability, up to a maximum recommended dose of 4 mg daily. For RLS, the safety and effectiveness of doses greater than 4 mg once daily have not been established.
The guidelines for managing Restless Legs Syndrome (RLS) with ropinirole include:
- Starting with a dose of 0.25 mg once daily 1 to 3 hours before bedtime
- Titration based on individual patient response and tolerability
- Maximum recommended dose of 4 mg daily
- Doses greater than 4 mg once daily have not been established as safe and effective 2
From the Research
Guidelines for Managing Restless Legs Syndrome (RLS)
The management of RLS involves both non-pharmacological and pharmacological interventions.
- Non-pharmacological interventions:
- Repetitive transcranial magnetic stimulation, exercise, compression devices, counterstrain manipulation, infrared therapy, and standard acupuncture may reduce RLS severity 3
- Vibration pads, cryotherapy, yoga, compression devices, and acupuncture may improve some sleep-related outcomes in RLS 3
- Good sleep hygiene, massaging the affected legs, taking hot baths, and performing mentally demanding tasks have been reported to reduce RLS symptoms 4
- Regular physical activity should be recommended for the treatment of RLS symptoms 5
- Pharmacological interventions:
- Dopaminergic agonists are considered the first-line treatment of RLS because they are more effective and produce augmentation less frequently as compared to L-dopa 4
- Opioids are prescribed to patients with severe conditions, especially those unresponsive to other treatments 4, 6
- Gabapentin, pregabalin, rotigotine, ropinirole, and pramipexole are considered effective for the short-term treatment of RLS 7
- Rotigotine is considered effective for the long-term treatment of RLS, while gabapentin enacarbil is probably effective, and ropinirole, pramipexole, and gabapentin are possibly effective 7
Treatment Options
Treatment options for RLS include:
- Non-pharmacological interventions such as lifestyle modifications and alternative therapies
- Pharmacological interventions such as dopaminergic agonists, opioids, and anticonvulsants
- Combination therapy, which may be considered for patients with severe RLS or those who do not respond to single-agent therapy 6, 7