Stay Current with Restless Legs Syndrome Treatment
Dopamine agonists (ropinirole, etc) are no longer first-line for restless legs syndrome (RLS), according to the Am Acad of Sleep Medicine. Physicians typically reach for these to help RLS symptoms quickly.
Now recent guidelines conditionally recommend AGAINST their use unless patients are prioritizing short-term benefits over long-term risks. That’s because evidence shows dopamine agonists are linked to risks with long-term use, including augmentation or worsening of symptoms. Plus their side effects include nausea, drowsiness, hallucinations, compulsive behaviours, etc.
Continue to help patients identify and manage exacerbating factors of RLS, such as alcohol, caffeine, untreated sleep apnea and certain medications, such as SSRIs, SNRIs, statins, and antihistamines. And since brain iron deficiency has gained recognition as a likely cause of RLS, iron supplementation is now considered first-line treatment.
Recommend checking serum iron, including ferritin and transferrin saturation, in ALL patients with RLS and supplement if needed. If symptoms persist after addressing exacerbating factors and iron deficiency, recommend GABAergic agents (gabapentin, pregabalin, etc).
- These medications reduce disease severity and do not cause augmentation.
- Explain that gabapentin or pregabalin usually takes some time to be titrated and may cause sedation and dizziness.
Save opioids as a last resort, for short-term use for more severe symptoms that don’t respond to other treatments. Don’t suggest benzos, they don’t have enough evidence of a benefit.
Advise reserving dopamine agonists for selective, short-term use, such as plane travel and using these medications at the lowest effective dose. Warn that pushing dopaminergic doses higher may improve symptoms short-term, but worsen symptoms in the long run.
Educate patients about the risk of augmentation with these medications and ask about worsening of RLS symptoms if taking a dopamine agonist. And if augmentation develops, suggest switching to gabapentin or pregabalin. Explain that abruptly discontinuing a dopamine agonist may lead to rebound symptoms and advise talking to their prescriber about tapering off the dopaminergic while titrating up the new medication.
References
- Winkelman JW, Berkowski JA, DelRosso LM, et al. Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2025;21(1):137-152.
