What is the recommended treatment for restless legs syndrome (RLS) without augmentation?

Restless Legs Syndrome Treatment Without Augmentation

Alpha-2-delta ligands (pregabalin or gabapentin) are recommended as first-line pharmacologic therapy for moderate to severe RLS due to their effectiveness and lower risk of augmentation compared to dopamine agonists. 1

Understanding RLS and Augmentation

Restless legs syndrome (RLS) is characterized by:

• An urge to move the legs accompanied by uncomfortable sensations
• Symptoms that begin or worsen during periods of rest
• Relief with movement
• Worsening of symptoms in the evening or night 1

Augmentation is a major concern in RLS treatment, characterized by:

• Earlier symptom onset
• Increased symptom intensity
• Spread of symptoms to other body parts 1
• Most commonly associated with dopaminergic medications, especially with long-term use 2

Treatment Algorithm for RLS Without Augmentation

Step 1: Rule Out Secondary Causes

• Check ferritin levels (treat if <50 ng/mL)
• Consider complete blood count, metabolic panel, liver function, thyroid function, HbA1c, and urine albumin:creatinine ratio 1

Step 2: Non-Pharmacological Approaches (First-Line)

• Regular aerobic and resistance exercise 1, 3
• Moderate exercise, smoking cessation, alcohol avoidance
• Caffeine reduction or elimination
• Discontinuation of potentially exacerbating medications 1
• Proper hydration throughout the day
• Consider sleeping with head of bed elevated (10°)
• Compression stockings if venous pooling is suspected 1

Step 3: Pharmacological Treatment for Moderate to Severe RLS

First-Line Medications:

• Alpha-2-delta ligands:
  • Pregabalin or gabapentin
  • Preferred due to lower risk of augmentation 1, 2
  • Potential side effects: sedation and dizziness 2

Second-Line Medications (Short-Term Use Only):

• Dopamine agonists:
  • Ropinirole: Start 0.25 mg orally 1-3 hours before bedtime 1, 4
  • Pramipexole: Start 0.125 mg orally 2-3 hours before bedtime 1
  • Rotigotine patch 1
  • Limit use due to high risk of augmentation 1, 2
  • Potential side effects: daytime sleepiness, impulse control disorders 2

Third-Line Medications:

• Opioids:
  • Consider for severe cases that fail to respond to first and second-line treatments 1, 5
  • Use with caution due to risk of central sleep apnea and respiratory depression 1
  • Can be effective for patients with augmentation when decreasing dopamine agonists 5

Special Populations

Patients with Chronic Kidney Disease (CKD) or End-Stage Renal Disease (ESRD):

• Gabapentin as first-line treatment 1
• IV iron sucrose for ESRD patients with ferritin < 200 ng/mL and transferrin saturation < 20% 1
• Consider vitamin C supplementation 1

Geriatric Patients:

• Start with lower doses and titrate slowly
• Monitor for orthostatic hypotension, especially with dopamine agonists 1

Monitoring and Follow-Up

• Regular monitoring for medication side effects, particularly augmentation with dopamine agonists 1
• Regular follow-up to assess symptom control and adjust treatment as needed 1
• Check ferritin levels and supplement when <50 ng/mL 1

Common Pitfalls to Avoid

1. Long-term use of dopamine agonists: Despite their effectiveness, prolonged use significantly increases augmentation risk. Limit duration when possible 1, 2

2. Overlooking iron deficiency: Always check ferritin levels and supplement when <50 ng/mL 1

3. Missing secondary causes: Thoroughly evaluate for conditions that can cause or exacerbate RLS 1

4. Inadequate dose adjustment: Minimal dose increases over time are typically needed; avoid rapid escalation 1

5. Failing to recognize augmentation: Watch for earlier symptom onset, increased intensity, and spread to other body parts 1