Restless legs syndrome: a new practice guideline

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Evidence shows strong support for prescribing pramipexole, rotigotine, cabergoline, or gabapentin enacarbil to treat adults with restless legs syndrome symptoms.
Evidence shows strong support for prescribing pramipexole, rotigotine, cabergoline, or gabapentin enacarbil to treat adults with restless legs syndrome symptoms.

The American Academy of Neurology (AAN) has released a new practice guideline for treating adults with restless legs syndrome (RLS), which was published in Neurology.

For the Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the AAN, John W. Winkelman, MD, PhD, and colleagues used articles classified by the 2004 (AAN) evidence rating scheme to make evidence-based recommendations regarding RLS management in adults. For RLS efficacy, the International Restless legs Syndrome Study Group rating scale (IRLS) was the preferred outcome.

In moderate to severe primary RLS, clinicians should consider prescribing medication specifically to reduce RLS symptoms. Stronger evidence supports pramipexole, rotigotine, cabergoline, and gabapentin enacarbil use (Level A); moderate evidence supports ropinirole, pregabalin, and IV ferric carboxymaltose use (Level B). Clinicians may also consider prescribing levodopa (Level C). Augmentation risks with dopaminergic agents should be considered.

When treating periodic limb movements of sleep, clinicians should consider prescribing ropinirole (Level A) or pramipexole, rotigotine, cabergoline, or pregabalin (Level B). For any other subjective sleep measures, clinicians should consider cabergoline or gabapentin enacarbil (Level A) or ropinirole, pramipexole, rotigotine, or pregabalin (Level B). For patients failing other treatments for RLS symptoms, clinicians may consider prolonged-release oxycodone/naloxone where available (Level C).

When non-pharmacologic approaches are desired, clinicians should consider prescribing pneumatic compression (Level B) and may consider near-infrared spectroscopy or transcranial magnetic stimulation (Level C). Clinicians may consider prescribing vibrating pads to improve subjective sleep (Level C). In patients on hemodialysis with secondary RLS, clinicians should consider vitamin C and E supplementation (Level B) and may consider prescribing ropinirole, levodopa, or exercise (Level C).

Reference

  1. Winkelman JW, Armstrong MJ, Allen RP, et al. Practice guideline summary: Treatment of restless leg syndrome in adults. Neurology. 16 November 2016. doi: http:/​/​dx.​doi.​org/​10.​1212/​WNL.​0000000000003388
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