New RLS Foundation Treatment Algorithm Offers Practical Guidance for Managing Restless Legs Syndrome

## A New Approach to Managing Restless Legs Syndrome The Restless Legs Syndrome (RLS) Foundation has published an updated treatment algorithm, offering practical guidance for clinicians in managing RLS. The algorithm replaces the 2021 version and is designed to complement the American Academy of Sleep Medicine's clinical practice guideline on RLS treatment. According to the RLS Foundation, the new algorithm is a response to the significant changes in RLS management over the past few years. ## Dopamine Agonists No Longer Recommended as First-Line Therapy One of the biggest changes in the new algorithm is the recommendation to stop prescribing dopamine agonists as first-line therapy for RLS. This is due to growing evidence of augmentation, a paradoxical worsening of RLS symptoms over time, associated with long-term use of dopamine agonists. The algorithm now firmly places gabapentinoids and iron therapy as the first-line treatments, with dopamine agonists only considered if these first-line agents fail or are not tolerated. ## Iron Therapy Expanded to Include Patients with Higher Serum Ferritin Levels The RLS Foundation algorithm also broadens the criteria for considering intravenous (IV) iron therapy. While the 2025 AASM guideline suggests IV iron for patients with a serum ferritin level up to 100 µg/L, the new algorithm recommends IV iron be considered for any patient with chronic persistent RLS and a serum ferritin level up to 300 µg/L and a transferrin saturation (TSAT) below 45%. This change is based on emerging evidence and a deeper understanding of iron's role in the brain. ## Managing RLS Augmentation The algorithm provides a practical guide to recognizing and managing RLS augmentation, a topic not fully addressed in the AASM guideline. Clinicians are advised to suspect augmentation in any patient on a dopamine agonist whose symptoms are worsening, and to never increase the dopamine agonist dose to treat augmentation symptoms. Management requires a slow, careful weaning of the dopamine agonist, often after starting an alternative agent like a gabapentinoid or a low-dose opioid. ## Low-Dose Opioids as a Key Therapeutic Option The algorithm elevates the role of low-dose opioids, positioning them as a key therapeutic option for patients who do not respond to or tolerate iron and gabapentinoids. When first-line treatments are exhausted, the choice between a dopamine agonist and a low-dose opioid requires a frank, shared decision-making conversation. ## Shared Decision-Making and Patient Education Throughout the document, the authors emphasize the importance of shared decision-making and patient education. This is particularly crucial when considering second- and third-line therapies, where the risk-benefit profiles become more complex. Clinicians are advised to educate patients on the long-term risks of dopamine agonists, including augmentation and impulse control disorders, as well as discussing the potential side effects and stigma associated with opioids. ## Nonpharmacological Treatment Options The algorithm includes bilateral high-frequency peroneal nerve stimulation, an FDA-approved nonpharmacological treatment for patients with moderate to severe RLS who have failed at least one medication. Clinical experience suggests it is a useful adjunctive therapy, particularly for patients who experience symptoms in the middle of the night.