Restless Legs Syndrome Management

Initial Assessment and Iron Status

The American Academy of Sleep Medicine recommends checking morning fasting iron studies, including serum ferritin and transferrin saturation, before starting any medication, with a strong recommendation for iron supplementation if ferritin ≤75 ng/mL or transferrin saturation <20% 1
IV ferric carboxymaltose is strongly recommended for patients meeting these iron parameters who don't respond to oral therapy, as an alternative to oral ferrous sulfate 1
Oral ferrous sulfate is conditionally recommended as an alternative iron supplementation option for patients with low ferritin or transferrin saturation levels 1

The American Academy of Sleep Medicine strongly recommends alpha-2-delta ligands, such as gabapentin, gabapentin enacarbil, or pregabalin, as first-line therapy with moderate certainty of evidence, due to their efficacy in reducing Restless Legs Syndrome symptoms 1
The American Academy of Sleep Medicine suggests initiating gabapentin at 300 mg three times daily, with titration by 300 mg/day every 3-7 days until reaching a maintenance dose of 1800-2400 mg/day, with doses up to 3600 mg/day being well-tolerated in clinical studies 1
Pregabalin is also strongly recommended as a first-line therapy, allowing for twice-daily dosing and potentially superior bioavailability compared to gabapentin 1

The American Academy of Sleep Medicine recommends eliminating or reducing caffeine and alcohol, discontinuing antihistaminergic and serotonergic medications, implementing moderate exercise and smoking cessation, and screening for and treating untreated obstructive sleep apnea, as concurrent non-pharmacological interventions to manage Restless Legs Syndrome symptoms 1, 2, 3

The American Academy of Sleep Medicine recommends confirming the diagnosis of Restless Legs Syndrome using the four essential criteria, checking morning fasting ferritin and transferrin saturation, and initiating iron supplementation if necessary, followed by gabapentin or pregabalin as first-line pharmacological treatment, with addressing exacerbating factors and monitoring for side effects and efficacy 1, 3