New Restless Legs Guidelines

The American Academy of Sleep Medicine published new guidelines for the treatment of restless legs (RLS) and leg jerks (PLMD). While aspects of the guidelines are clarifying, some ideas will be viewed as novel, impractical, or exaggerated.

The biggest change is the upgrade of the gabapentin-derivative drugs as now the best of the 1st line agents for RLS. The dopamine agents (widely in use for decades) are now downgraded, because of the augmentation problem, where the drug actually worsens the leg movements. The oddity here is that huge numbers of patients are successfully using dopamine drugs without this side-effect….as of yet! So, it remains unanswered whether such a patient would switch to a different drug now or wait until the augmentation side effect arises.

Opioid medications are still considered important agents for the treatment of RLS.

The most peculiar aspect of the guidelines is the absence of any clear treatment options for leg jerks, the movement of legs while sleeping. When I first trained in sleep medicine in the early 1990s, RLS and PLMD were simply considered waking and sleeping versions of the same condition, and therefore a single medication would treat both.

Many sleep doctors still practice using this theory, but there continues to be a never-ending group of experts that do not give much credence to an “independent” leg movement disorder. Instead, they seem to be convinced most leg jerks should subside with adequate treatment of sleep-breathing disorders.

We often found leg jerks a much more complicated condition, so we were surprised by the limited information forthcoming in these new guidelines.