The American Academy of Sleep Medicine recently published new clinical practice guidelines for restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) in adults and pediatric patients. The new guidelines advise against using dopamine agonists to treat RLS — the standard of care for the last 20 years — due to valid concerns about the drugs’ physiological and psychological adverse effects.

“Dopamine agonists, such as ropinirole and pramipexole, reduce RLS symptoms at first, but they have serious consequences with long-term use. Patients build up a tolerance, and as the doses go up, so do the drugs’ side effects such as dependency, worsening RLS symptoms, and compulsive disorders,” says Andrew R. Spector, MD, Duke neurologist, sleep medicine specialist, and author of the recent book Navigating Life with Restless Legs Syndrome.

RLS is a relatively common condition affecting up to 10% of adults and 4% of children in the U.S. This new standardized guideline will benefit many patients with safer first-line treatments. “A select number of RLS specialists have avoided these drugs for years, but now the guidelines have caught up with clinical practice,” says Spector.

When patients with RLS begin taking dopamine agonists, they typically experience resolution of their symptoms. With time, however, patients need higher doses to get the same relief. Many patients ultimately reach a point where there’s a reverse effect, and symptoms worsen.

“Patients come to me with terrible RLS symptoms and severe physical and psychological complications from dopamine agonists,” says Spector. “The brain becomes dependent on an exogenous source of dopamine. Mental health suffers with compulsive disorders, and it can take medical intervention to come off of these drugs due to extreme withdrawal.”

Dopamine agonists can still be a safe treatment, but only if used for selective, short-term purposes, like a patient who is taking a long flight and needs symptom relief.

The new guidelines emphasize regularly testing serum iron levels, including ferritin and transferrin saturation. “Iron therapy can be very effective. The new guidelines recommend it as a first-line treatment,” says Spector.

Other first-line alternatives to dopamine agonists for adults now include gabapentin and pregabalin as the sole first agent, in addition to dipyridamole in combination with a very low–dose opioid. For more refractory cases, a controlled dose of opioids can be an effective option for patients who can’t take gabapentin.

“If you have a patient with RLS symptoms, refer them to us. We have effective and safe treatments to offer,” says Spector.