Restless Legs Syndrome (RLS), also known as Willis-Ekbom Disease, primary RLS, and idiopathic RLS, is a neurological disorder characterized by unpleasant sensations in the legs and an irresistible urge to move them. The Centers for Disease Control (CDC) estimates that up to 7-10% of the US population may be affected by RLS, with onset possible at any age. While both males and females can experience RLS, females are more likely to be affected. The symptoms of RLS tend to worsen with age, particularly in middle-aged or older individuals.

Unfortunately, RLS is a lifelong condition with no known cure. However, there are RLS treatment options available to help alleviate symptoms. The American Academy of Sleep Medicine (AASM) has convened a task force of sleep medicine experts to update the 2012 Restless Leg Syndrome Practice Parameters, resulting in the 2024 AASM Restless Leg Syndrome Guidelines. This review aims to provide valuable insights into the changes in the management and treatment of RLS over the past decade.

While both documents reflect a comprehensive understanding of the disorder, there are notable differences between the two in terms of diagnostic criteria, treatment approaches, and recommendations for managing specific aspects of RLS. By examining these updates, we can gain a better understanding of how the field of sleep medicine has evolved in addressing RLS and improving patient outcomes.

Guidelines Referenced

Major Changes and Key Takeaways (2012 – 2024) 
  • Diagnosis
    • 2012 Practice Parameters: The 2012 guidelines followed the diagnostic criteria set by the International Restless Legs Syndrome Study Group (IRLSSG), which includes:
      • An urge to move the legs.
      • Worsening of symptoms during rest or inactivity.
      • Relief with movement.
      • Worsening of symptoms in the evening or night.
    • AASM Guidelines (2024): The diagnostic criteria have not changed significantly from the 2012 practice parameter. However, the AASM 2024 guidelines provide additional clarity on the severity of symptoms and emphasize ruling out secondary causes of RLS (such as iron deficiency, renal failure, or peripheral neuropathy) more explicitly. They also recommend considering the impact of RLS on quality of life and daytime functioning, which was less explicitly addressed in 2012.

  • Pharmacological Treatment
    • 2012 Practice Parameters:
      • Dopamine Agonists: The 2012 guidelines suggested dopamine agonists (e.g., pramipexole, ropinirole) as the first-line treatment for moderate to severe RLS.
      • Gabapentin: This was also recommended, especially for patients who could not tolerate dopamine agonists.
      • Iron Supplementation: Iron was suggested for patients with low ferritin levels, though its role was considered adjunctive rather than a primary therapy.
      • Opioids: These were considered for refractory cases, but only if symptoms were severely disruptive and unresponsive to other treatments.

  • AASM Guidelines (2024):
    • Dopamine Agonists: Dopamine agonists remain a first-line treatment. However, the AASM 2024 guidelines highlight a more cautious approach to their use, specifically due to concerns about augmentation (a phenomenon where symptoms worsen or start earlier with long-term use of these medications). The guidelines advise close monitoring and adjusting therapy if augmentation occurs.
    • Iron Supplementation: The 2024 guidelines strongly emphasize iron therapy for patients with ferritin levels below 75 mcg/L, regardless of the presence of anemia. This reflects an increasing understanding of iron’s role in RLS pathophysiology.
    • Gabapentinoids: Gabapentin and pregabalin are more strongly recommended for RLS patients who do not tolerate dopamine agonists, as they help manage symptoms and may have a more favorable side-effect profile.
    • Opioids: The 2024 guidelines recommend opioids as a last resort in severe cases of RLS. This reflects a growing concern about opioid misuse and side effects, suggesting that opioids should be prescribed sparingly, and only after other options have been exhausted.

  • Non-Pharmacological Treatments
    • 2012 Practice Parameters: The 2012 guidelines did mention non-pharmacological treatments like improving sleep hygiene, regular exercise, and leg massage, but these were not emphasized as primary interventions. Psychological interventions like cognitive behavioral therapy (CBT) were only briefly touched upon.
    • AASM Guidelines (2024): The 2024 guidelines place more emphasis on lifestyle changes and non-pharmacological therapies. CBT is now recommended for managing mild to moderate RLS, especially in patients who do not respond well to medications. The guidelines also stress the importance of relaxation techniques, moderate exercise, and sleep hygiene. It suggests that pneumatic compression devices and acupuncture could also be considered in specific cases, although the evidence supporting these treatments remains somewhat limited.

  • Management of Augmentation
    • 2012 Practice Parameters: Augmentation, which is the worsening of symptoms with long-term use of dopamine agonists, was recognized as a potential complication of therapy, but there was less detailed guidance on managing it.
    • AASM Guidelines (2024): The updated guidelines place much more emphasis on augmentation as a significant concern with dopamine agonists. They advise regular monitoring for signs of augmentation, such as earlier onset of symptoms and increased intensity, and suggest adjusting treatment strategies if it occurs. This includes tapering off the dopamine agonists or switching to other medications such as gabapentinoids or iron supplementation.

  • Opioid Use
    • 2012 Practice Parameters: Opioids were considered a second- or third-line option for refractory cases of RLS, though their use was limited by potential side effects and concerns about dependence.
    • AASM Guidelines (2024): The 2024 guidelines recommend a more restrictive approach to opioid use, advising opioids be used only in severe, treatment-refractory cases, and only after considering other treatment options. This change reflects increasing concerns about the opioid crisis and a more cautious stance on their use.

  • Emerging Therapies
    • 2012 Practice Parameters: The 2012 guidelines did not focus on new or emerging therapies beyond traditional treatments.
    • AASM Guidelines (2024): The newer guidelines discuss emerging treatments like pneumatic compression devices, acupuncture, and biofeedback as potential options for patients, although the evidence supporting these therapies is still developing.

  • Summary of Key Differences:
    • Iron Supplementation: The AASM 2024 guidelines emphasize iron therapy more strongly, particularly for low ferritin levels, whereas the 2012 practice parameters considered it a secondary option.
    • Augmentation: The 2024 guidelines place greater emphasis on the potential for augmentation with dopamine agonists and recommend closer monitoring and alternative treatments when it occurs.
    • Opioids: The 2024 guidelines take a more cautious approach, recommending opioids only as a last resort in severe cases. The 2012 practice parameters were more lenient in using opioids as a second- or third-line option.
    • Non-Pharmacological Treatments: The 2024 guidelines provide a stronger emphasis on lifestyle interventions (moderate exercise, sleep hygiene) and psychological therapies (like CBT), reflecting growing evidence of their benefit. The 2012 practice parameters mentioned lifestyle changes but had less detail on psychological therapies.
    • Emerging Therapies: The 2024 guidelines show more openness to emerging therapies such as acupuncture, pneumatic compression devices, and yoga, while the 2012 practice parameters did not highlight these treatments.
    • Follow-Up: The 2024 guidelines emphasize the need for ongoing monitoring and adjustment of treatment, particularly to prevent the development of augmentation and ensure treatment efficacy.

In summary, the 2024 AASM RLS Guidelines emphasize a more personalized, cautious, and holistic approach, with greater focus on iron supplementation, augmentation management, psychological interventions, and emerging therapies. In contrast, the 2012 RLS Practice Parameters was more focused on traditional pharmacological treatments and less detailed in terms of lifestyle interventions and patient monitoring.

We are grateful for your ongoing interest, and we encourage you to stay informed about upcoming segments in our series. We value your feedback and would like to hear your suggestions for future topics to be covered in our guideline series. Please feel free to contact us with any ideas or questions you may have.

Sign up for alerts and stay informed on the latest published guidelines and articles.

Copyright © 2024 Guideline Central, All Rights Reserved.