Guidelines for the first-line treatment of restless legs syndrome/Willis–Ekbom disease, prevention and treatment of dopaminergic augmentation: a combined task force of the IRLSSG, EURLSSG, and the RLS-foundation

Abstract

A Task Force was established by the International Restless Legs Syndrome Study Group (IRLSSG) in conjunction with the European Restless Legs Syndrome Study Group (EURLSSG) and the RLS Foundation (RLS-F) to develop evidence-based and consensus-based recommendations for the prevention and treatment of long-term pharmacologic treatment of dopaminergic-induced augmentation in restless legs syndrome/Willis-Ekbom disease (RLS/WED). The Task Force made the following prevention and treatment recommendations: As a means to prevent augmentation, medications such as α2δ ligands may be considered for initial RLS/WED treatment; these drugs are effective and have little risk of augmentation. Alternatively, if dopaminergic drugs are elected as initial treatment, then the daily dose should be as low as possible and not exceed that recommended for RLS/WED treatment. However, the physician should be aware that even low dose dopaminergics can cause augmentation. Patients with low iron stores should be given appropriate iron supplementation. Daily treatment by either medication should start only when symptoms have a significant impact on quality of life in terms of frequency and severity; intermittent treatment might be considered in intermediate cases. Treatment of existing augmentation should be initiated, where possible, with the elimination/correction of extrinsic exacerbating factors (iron levels, antidepressants, antihistamines, etc.). In cases of mild augmentation, dopamine agonist therapy can be continued by dividing or advancing the dose, or increasing the dose if there are breakthrough night-time symptoms. Alternatively, the patient can be switched to an α2δ ligand or rotigotine. For severe augmentation the patient can be switched either to an α2δ ligand or rotigotine, noting that rotigotine may also produce augmentation at higher doses with long-term use. In more severe cases of augmentation an opioid may be considered, bypassing α2δ ligands and rotigotine.

New concepts in the management of restless legs syndrome

“…This study reported that gabapentin enacarbil (1200 mg/ completely but to ensure that they do not interfere with quality of life. 153 If symptoms become bothersome, the dose can be increased cautiously, but this will increase the risk of development of augmentation. 153 A non-dopaminergic agent can be added if concerns about the dose of the dopaminergic drug occur.…”

Restless Legs Syndrome: clinical features, diagnosis and a practical approach to management

“…Given the high risk of augmentation with dopaminergic medications, a calcium channel α2δ ligand is often preferred over dopamine agonists for long-term therapy 4. New guidelines were published in 2016 for the first-line treatment of RLS and prevention of dopaminergic augmentation.…”

“…New guidelines were published in 2016 for the first-line treatment of RLS and prevention of dopaminergic augmentation. These guidelines encourage the use of calcium channel α2δ ligands as first-line treatment in RLS over dopamine agonist 4. A dopamine agonist can be still used as first-line therapy but requires close follow-up to identify early signs of augmentation.…”

Rotigotine Transdermal Patch: A Review in Restless Legs Syndrome

“…One international guideline suggests the prevention of augmentation from the outset, by initiating RLS treatment in de novo patients with non-dopaminergic drugs, such as a2d ligands [41]; however, these options are not always available (e.g. the a2d ligand gabapentin enacarbil is not currently approved for RLS treatment in the EU [4,41]). Longer-acting dopamine receptor agonists at lower dosages have a lower likelihood of causing augmentation [1,3].…”

“…5). The use of rotigotine is recommended as an option in cases of augmentation, although the guideline states that long-term treatment with rotigotine at higher dosages may also result in augmentation [41].…”