Restless leg syndrome: New guideline includes significant changes including bigger focus on iron levels

A new clinical practice guideline from the American Academy of Sleep Medicine (AASM), offers significant changes, including a new first-line treatment for restless leg syndrome (RLS). Numerous clinical trials and longitudinal studies have informed the guideline, last updated in 2012.One of the key changes in the new guideline is a stronger focus on assessing iron levels in all patients with RLS. Depending on those results, iron supplementation is now recommended, based on growing evidence that low brain iron is a major contributor to the condition. For adults, the guideline gives a strong recommendation for IV ferric carboxymaltose, along with conditional recommendations for two other IV iron options and oral ferrous sulfate. In children, ferrous sulfate received a conditional recommendation and is currently the only treatment supported for pediatric RLS.Another change is that the AASM no longer recommends using dopaminergic agonists as first-line treatment.The new guideline takes a step back from the standard use of pramipexole and ropinirole, issuing conditional recommendations against them. That’s a shift from the 2012 guidance, which strongly supported both. Over the past decade, research has shown that long-term use of these and other dopaminergic medications can lead to augmentation—a gradual worsening of RLS symptoms in both intensity and duration.Instead, the guideline now strongly recommends three alpha-2-delta ligand calcium channel blockers— gabapentin enacarbil, gabapentin, and pregabalin—as first-line options. These medications are not linked to the risk of augmentation seen with dopaminergic agents.'Turning point'“This new clinical practice guideline from the AASM represents an important turning point in the treatment of RLS in adults,” said Dr. John Winkelman, chair of the AASM task force and professor of psychiatry at Harvard Medical School. “Guided by the best evidence in the scientific literature, we’ve provided recommendations that will improve the ability of clinicians to provide patient-centered care for people who have RLS,” said Dr. Winkelman, also chief of the sleep disorders clinical research program at Massachusetts General Hospital.The guideline also introduces conditional support for a newer therapy: bilateral high-frequency peroneal nerve stimulation. This treatment, which involves wearing a device that stimulates the nerves in the legs before bedtime, received a conditional recommendation based on emerging evidence since the last update.Low-dose, extended-release oxycodone and other low-dose opioids also received conditional support in the updated guideline. While these medications have shown effectiveness in treating RLS, the authors emphasized that they carry risks and should be used with care and close clinical monitoring.Exacerbating factors for the disorder, the authors noted, include alcohol, caffeine, certain antidepressant and antihistamine medications and untreated obstructive sleep apnea.RLS affects 5%-to-10% of the Canadian population. It's characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations. It occurs most often in the evening or at night, while sitting or lying down. While RLS can be intermittent, chronic cases are more common. The prevalence of RLS-related symptoms increases with age and more common during pregnancy.The new guideline was published in the Journal of Clinical Sleep Medicine.

Restless leg syndrome: New guideline includes significant changes including bigger focus on iron levels

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