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The American Academy of Sleep Medicine (AASM) has released new Clinical Practice Guidelines aimed at the treatment of restless legs syndrome (RLS). The revised guidelines notably advise against the routine use of dopamine agonists, which have been linked to a troubling side effect known as augmentation.1
Augmentation is defined as the troubling phenomenon where symptoms of RLS not only worsen in frequency but also spread to other parts of the body. First documented three decades ago, recent studies have shown that dopaminergic treatments can trigger this condition in an estimated 7 to 10% of patients annually.2
“While 7 to 10% may not appear significant at first glance, the reality is concerning. For individuals with restless leg syndrome who require ongoing treatment, the cumulative incidence over just three years can rise to 20 to 30%, and in five years, it may jump to an alarming 35 to 50%,” explained John Winkelman, MD, PhD, who leads the sleep disorders clinical research program at Massachusetts General Hospital and oversees the AASM’s guideline revisions.
In their evaluation, the AASM committee carefully considered both the efficacy of dopamine agonists and the potential adverse effects associated with long-term use. Ultimately, they concluded that while these medications may be effective in the short term, the risk of serious long-term complications significantly outweighs any transient benefits.1
Winkelman noted the lack of reliable methods for assessing brain iron levels. However, clinical research indicates that maintaining serum ferritin levels above 100 ng/mL and serum transferrin saturation greater than 20% can significantly benefit patients suffering from RLS.
“Many providers might consider a ferritin level of 15 or 20 to be just slightly low, yet for someone with restless leg syndrome, those figures are far too inadequate. We strive to elevate the ferritin levels beyond 100, alongside optimizing transferrin saturation,” Winkelman emphasized, highlighting a shift in treatment philosophy.
He further advised clinicians to recommend patients avoid iron supplements or red meat for 48 hours before conducting any iron level checks. This approach is essential for obtaining a more accurate assessment of iron status, which is crucial for RLS management.
Gabapentin enacarbil, gabapentin, and pregabalin have emerged as effective alternatives for the majority of RLS patients, Winkelman remarked.
“For individuals who also experience neuropathy or similar chronic pain syndromes, these medications may provide dual benefits, addressing both conditions effectively,” he added.
He recommends a cautious approach for patients exhibiting sensitivities to medication side effects, suggesting a “low and slow” initiation of treatment schedules. Certain patients, particularly those prone to balance issues, weight gain, or dizziness, may require this adjusted dosing strategy. Despite individual variations in tolerance, clinical trials have demonstrated the effectiveness of these medications, reinforcing their position as first-line treatments for RLS.
“These revisions represent significant changes for healthcare providers. During every consultation with a patient prescribed dopaminergic medication, it’s imperative to inquire about the timeline of their symptoms to ensure augmentation isn’t developing. This phenomenon is typically gradual but becomes accelerated with an increase in dosage—a common reaction when initial treatments seem inadequate,” Winkelman warned.
References
- Winkelman JW, Berkowski JA, DelRosso LM, Koo BB, Scharf MT, Sharon D, Zak RS, Kazmi U, Falck-Ytter Y, Shelgikar AV, Trotti LM, Walters AS. Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2024 Sep 26. doi: 10.5664/jcsm.11390. Epub ahead of print. PMID: 39324694.
- Zeng P, Wang T, Zhang L, Guo F. Exploring the causes of augmentation in restless legs syndrome. Front Neurol. 2023 Sep 28;14:1160112. doi: 10.3389/fneur.2023.1160112. PMID: 37840917; PMCID: PMC10571710.
Restless Legs Syndrome: Time to Step Aside from Dopamine?
Ah, restless legs syndrome (RLS) – that little dance party your legs throw in the middle of the night without so much as an invite! But fear not, because the American Academy of Sleep Medicine (AASM) has just shaken up the RLS treatment game. And it seems the dopamine agonists, once the acclaimed headliners for RLS treatment, are being given the boot due to a rather pesky issue known as augmentation. That’s right, folks—it’s not ‘one more song,’ it’s more like ‘please, stop the music!’
Let’s break it down. Augmentation, the medical term for when RLS symptoms get creatively worse over time, was first spotted thirty years ago. And oh boy, it’s like something out of a horror film for those poor souls who are unfortunate enough to suffer from RLS. As if the usual symptoms don’t keep you tossing and turning enough, now you have to deal with the fact that 7 to 10 percent of patients per year might find themselves in an escalated state. Do the math, and that’s almost half of the crowd after a couple of years—where’s the fun in that?
Dr. John Winkelman, the maestro behind this latest guideline revision, put it succinctly, stating this new insight means it’s time to ditch the standard dopamine agonists for long-term treatments. A shot in the arm for some, a shot in the foot for many! Who wants to play the augmentation roulette, right?
But don’t despair just yet! The AASM committee isn’t leaving patients high and dry; they’ve favorably suggested keeping an eye on iron levels. Yes, that thing you’ve been ignoring since your school science fair project. Turns out, a serum ferritin greater than 100 and serum transferrin saturation above 20% can be effective for RLS. And here I was, thinking ferritin was just an obscure element on the periodic table that no one ever cared about. But no, it’s a patrolling guardian of your leg sanity!
Dr. Winkelman advocates for a good old-fashioned iron check-up. I mean, who knew that giving up iron vitamins and red meat for 48 hours could lead to better insight into how ‘iron deficient’ your life has truly become? Talk about commitment – it’s like a detox diet, just without the kale smoothies and Instagram posts!
Now, for the backups: gabapentin and its cousins, gabapentin enacarbil and pregabalin! Just when you thought we were done with the pharmaceuticals, here comes the cavalry! Even if you have neuropathy or chronic pain, these meds could potentially resolve more than one issue at a time. That’s what I call multitasking!
Dr. Winkelman also stresses a ‘start low and go slow’ mantra for those who are more sensitive to side effects. In other words, let’s treat RLS patients like fine wine—savor it slowly, rather than chugging it back like a frat party! And the good doctor’s advice on monitoring symptom timing is refreshingly clear: you don’t just pop pills like candy and hope for the best. Unless you’re trying to augment your problems, in which case, keep drinking those energy drinks!
These new approaches are certainly a wake-up call for doctors everywhere. Set your reminders, because every visit to a patient on dopaminergic medication should now come with a subtle inquiry about augmentation. It’s a bit like asking how many times your mate has been to the dentist—embarrassing, but necessary!
So, there you have it! RLS treatment is stepping out of the shadow of dopamine agonists and into the light of iron checks and new medications. Let’s hope they can finally get those pesky legs to lay off the after-party and let their owners rest in peace. Remember, if your legs are restless, it’s time to take a step in the right direction. Literally!
References
- Winkelman JW, 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. 2024 Sep 26. doi: 10.5664/jcsm.11390.
- Zeng P, et al. Exploring the causes of augmentation in restless legs syndrome. Front Neurol. 2023 Sep 28;14:1160112. doi: 10.3389/fneur.2023.1160112.
And there you have it! RLS treatment has taken a fresh, ironic turn, and I promise you, it’s worth every chuckle while we navigate through this nocturnal mess! Take that restless crowd, and keep those legs in check!
