Treatment of Restless Leg Syndrome

Initial Assessment and Diagnosis

The American Geriatrics Society recommends checking serum iron studies, including ferritin and transferrin saturation, as iron deficiency is often associated with Restless Leg Syndrome (RLS) 1, 2
Consider iron supplementation if ferritin ≤75 ng/mL or transferrin saturation <20% 2
Evaluate for secondary causes such as peripheral neuropathy or radiculopathy through a thorough neurological examination 1
Identify and discontinue medications that may exacerbate RLS symptoms, including antihistamines and certain antidepressants 2

The American Geriatrics Society suggests implementing moderate exercise, smoking cessation, alcohol avoidance, and caffeine reduction or elimination as non-pharmacological approaches 1
Address any underlying conditions that may contribute to RLS symptoms 2
Alpha-2-delta ligands (gabapentin, pregabalin, or gabapentin enacarbil) are recommended as first-line pharmacological treatment due to their efficacy and lower risk of augmentation compared to dopaminergic agents 2

Gabapentin: Start with low doses and titrate as needed 2
Pregabalin: Effective alternative with similar mechanism 2
Gabapentin enacarbil: Extended-release formulation with improved bioavailability 2
Iron therapy if iron deficiency is present: Oral ferrous sulfate for patients with ferritin ≤75 ng/mL or transferrin saturation <20% 2
Consider IV iron (ferric carboxymaltose) if oral therapy is ineffective 2

Dopamine agonists (with caution in elderly): Ropinirole and Pramipexole, with careful monitoring for augmentation 1, 2
The American Academy of Sleep Medicine suggests against standard use of dopamine agonists due to risk of augmentation 2, 3
Opioids for refractory cases: Extended-release oxycodone or other opioids may be considered for severe cases that don't respond to first-line treatments 2

Start with lower doses of medications and titrate slowly to minimize side effects 1
Be vigilant about potential drug interactions with other medications 1
Monitor for orthostatic hypotension, particularly with dopamine agonists 1
Consider fall risk when selecting medications, with alpha-2-delta ligands generally having a better safety profile than dopamine agonists in the elderly 2

Watch for augmentation if using dopamine agonists, characterized by earlier onset of symptoms, increased symptom intensity, and spread of symptoms to other body parts 1, 2, 3
If augmentation occurs, consider taking medication doses earlier in the day, splitting existing doses, or switching to an alpha-2-delta ligand or opioid 1, 2

The American Geriatrics Society recommends being cautious with benzodiazepines in elderly patients as they can cause decreased cognitive performance 4