What is the diagnosis and treatment for Restless Legs Syndrome (RLS)?

From the Guidelines

Restless leg syndrome (RLS) should be treated with ferrous sulfate in patients with appropriate iron status, as it is suggested by the American Academy of Sleep Medicine (AASM) with moderate certainty of evidence 1. The treatment of RLS involves a combination of lifestyle modifications and pharmacological interventions. For mild RLS, lifestyle modifications such as regular exercise, maintaining good sleep hygiene, avoiding caffeine and alcohol, and practicing relaxation techniques are recommended first.

Key Treatment Options

• Ferrous sulfate: The AASM suggests the use of ferrous sulfate over no ferrous sulfate in patients with appropriate iron status, with moderate certainty of evidence 1.
• Dipyridamole: The AASM suggests the use of dipyridamole over no dipyridamole, with low certainty of evidence 1.
• Extended-release oxycodone and other opioids: The AASM suggests the use of extended-release oxycodone and other opioids over no opioids, with moderate certainty of evidence 1.
• Bilateral high-frequency peroneal nerve stimulation: The AASM suggests the use of bilateral high-frequency peroneal nerve stimulation over no peroneal nerve stimulation, with moderate certainty of evidence 1.

Special Considerations

• Levodopa, pramipexole, transdermal rotigotine, and ropinirole: The AASM suggests against the standard use of these medications, with varying levels of certainty of evidence 1.
• Gabapentin, IV iron sucrose, and vitamin C: The AASM suggests the use of these medications in adults with RLS and end-stage renal disease (ESRD), with varying levels of certainty of evidence 1. It is essential to note that the treatment of RLS should be individualized, and the choice of medication should be based on the patient's specific needs and medical history. Regular follow-up is crucial to monitor symptom control and medication side effects.

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 Leg Syndrome (RLS).

• The drug has been shown to reduce the severity of RLS symptoms, as measured by the International RLS Rating Scale (IRLS scale) and the Clinical Global Impression-Global Improvement (CGI-I) scores.
• The mean dose at Week 12 was approximately 2 mg/day for the 3 trials.
• Long-term maintenance of efficacy in the treatment of RLS was demonstrated in a 36-week trial 2.

From the Research

Definition and Characteristics of Restless Leg Syndrome

• Restless legs syndrome (RLS) is characterized by an uncomfortable urge to move the legs while at rest, relief upon movement or getting up to walk, and worsened symptom severity at night 3.
• RLS may be primary (idiopathic) or secondary to pregnancy or a variety of systemic disorders, especially iron deficiency, and chronic renal insufficiency 3.
• The clinical hallmarks of RLS include dysesthesias or paresthesias in the legs and sometimes the arms, occurring primarily at rest, which are usually worse in the evening and are alleviated by movement 4.

Treatment Options for Restless Leg Syndrome

• Dopaminergic agents are the best-studied agents, and are considered first-line treatment of RLS 5.
• First-line management options include iron-replacement therapy in those with evidence for reduced body-iron stores or, alternatively, with prescribed gabapentin or pregabalin, and dopamine agonists such as pramipexole, ropinirole, and rotigotine 3.
• Second-line therapies include intravenous iron infusion in those who are intolerant of oral iron and/or those having augmentation with intense, severe RLS symptoms, and opioids including tramadol, oxycodone, and methadone 3.
• Non-pharmacological measures such as massage or temperate baths can provide adequate symptom control for some people with RLS 3.
• Complementary and alternative therapies, including exercise training, transcutaneous spinal direct current stimulation, pneumatic compression devices, light therapy, repetitive transcranial magnetic stimulation, and acupuncture, have been found to be effective in both primary and secondary RLS 6.

Management and Special Considerations

• The management of RLS is considered under the following headings: General Considerations; Intermittent RLS; Chronic Persistent RLS; Refractory RLS; Special Circumstances; and Alternative, Investigative, and Potential Future Therapies 7.
• Nonpharmacologic approaches, including mental alerting activities, avoidance of substances or medications that may exacerbate RLS, and oral and intravenous iron supplementation, are outlined 7.
• Treatment of RLS in pregnancy and childhood is discussed, and 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 7.