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New guidance from the American Academy of Sleep Medicine (AASM) marks significant shifts in restless leg syndrome (RLS) treatment protocols, particularly regarding iron supplementation and medication choices. The updated clinical practice guideline, published in the Journal of Clinical Sleep Medicine, introduces evidence-based recommendations that challenge previous standards from 2012, notably reversing positions on commonly prescribed dopamine agonists while emphasizing iron evaluation and supplementation.
Key Points:
- Iron therapy takes center stage with strong recommendations for intravenous ferric carboxymaltose in adults, alongside conditional support for two additional IV iron formulations and oral ferrous sulfate. For pediatric cases, ferrous sulfate stands as the sole recommended treatment option.
- The guideline now advises against routine use of dopamine agonists (pramipexole and ropinirole) due to evidence linking long-term use with symptom augmentation. This represents a notable reversal from previous guidance.
- Three alpha-2-delta ligand calcium channel blockers receive strong recommendations: gabapentin enacarbil, gabapentin, and pregabalin, based on their efficacy without associated symptom progression.
- Initial management should target modifiable factors, including alcohol, caffeine, specific medications (antihistamines, serotonergics, anti-dopaminergics), and untreated sleep apnea.
- New treatment modalities gain conditional support, including bilateral high-frequency peroneal nerve stimulation and carefully monitored low-dose extended-release oxycodone/opioids.
HCN Medical Memo
This guidance fundamentally alters the RLS treatment algorithm, prioritizing iron supplementation and alpha-2-delta ligands while moving away from dopaminergic agents. Consider reassessing current RLS patients on traditional therapies in light of these recommendations.
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