What are the treatment options for Restless Legs Syndrome (RLS)?

From the Guidelines

Restless leg syndrome can be effectively treated with a combination of lifestyle changes and medications, with the most recent evidence suggesting the use of gabapentin, pregabalin, or IV ferric carboxymaltose as first-line treatments 1. To manage restless leg syndrome, it's essential to start with lifestyle modifications, including improving sleep habits, reducing caffeine and alcohol intake, and engaging in regular moderate exercise. For immediate relief, gentle stretching, massaging the legs, or applying warm or cold packs can be beneficial. Key considerations for treatment include:

• Iron supplements, such as ferrous sulfate, may help if there's an iron deficiency, a common underlying cause of restless leg syndrome 1.
• Medication options include gabapentin, pregabalin, or IV ferric carboxymaltose, which are recommended as first-line treatments based on recent evidence 1.
• Dopamine agonists like pramipexole or ropinirole may be considered, but with caution due to the risk of augmentation, where symptoms worsen or begin earlier in the day with long-term use 1.
• Alpha-2-delta calcium channel ligands, such as gabapentin or pregabalin, are alternatives, especially if pain is a component of the symptoms.
• For severe cases, low-dose opioids might be prescribed, but with caution due to the risk of central sleep apnea and respiratory depression 1. It's crucial to rotate between different medication classes to prevent augmentation and to regularly assess the patient's response to treatment, adjusting the approach as needed to optimize outcomes in terms of morbidity, mortality, and quality of life.

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. In all 3 trials, a statistically significant difference between the treatment group receiving ropinirole and the treatment group receiving placebo was observed at Week 12 for both the mean change from baseline in the IRLS scale total score and the percentage of patients rated as responders (much improved or very much improved) on the CGI-I

Ropinirole is effective in the treatment of Restless Legs Syndrome (RLS).

• The medication has been shown to reduce symptoms of RLS, as measured by the International RLS Rating Scale (IRLS scale) and the Clinical Global Impression-Global Improvement (CGI-I) scores.
• Patients with RLS who received ropinirole had a statistically significant improvement in symptoms compared to those who received placebo 2.
• The recommended dosage of ropinirole for RLS is 0.25 mg to 4 mg once daily, taken 1 to 3 hours before bedtime.
• Long-term maintenance of efficacy in the treatment of RLS was demonstrated in a 36-week trial 2.

From the Research

Restless Leg Treatment Options

• Non-pharmacological measures such as massage or temperate baths can provide adequate symptom control for some people with Restless Legs Syndrome (RLS) 3.
• First-line management options include iron-replacement therapy, gabapentin, pregabalin, and dopamine agonists such as pramipexole, ropinirole, and rotigotine 3, 4.
• Second-line therapies include intravenous iron infusion and opioids such as tramadol, oxycodone, and methadone 3, 5.

Pharmacological Treatment

• Dopaminergic agents are considered first-line treatment for RLS, with extensive data available for levodopa and dopamine agonists such as pramipexole and ropinirole 4, 6.
• The choice of an alpha2-delta ligand as first-line therapy for chronic persistent RLS, with dopamine agonists as a second-line option, is explained in the updated algorithm for the management of RLS 7.
• Combination therapy and the use of high-potency opioids may be considered for refractory RLS 7.

Special Considerations

• Treatment of RLS in pregnancy and childhood requires special consideration, with limited data available on the safety and efficacy of dopaminergic agents in these populations 7, 6.
• Nonpharmacologic approaches, including mental alerting activities and avoidance of substances or medications that may exacerbate RLS, may be beneficial for some patients 7.