To reduce the risk for complications, the use of dopaminergic agonists in the treatment of severe restless legs syndrome (RLS) has become less common.
RLS is characterised by an irresistible urge to move the legs, often accompanied by unpleasant sensations such as itching, tingling, or electric paresthesia, which typically affect the lower limbs. It affects 8% of the French population, predominantly women.
New guidelines from the American Academy of Sleep Medicine (AASM) no longer recommend the use of these drugs as first-line treatments.
During the recent French Language Neurology Days in Montpellier, France, Sofiène Chenini, PhD, a researcher at the Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, reviewed the current treatment approaches for RLS and highlighted non-dopaminergic alternatives. He cautioned that dopaminergic agonists could lead to the augmentation and worsening of symptoms over time.
In France, RLS is guided by the 2019 recommendations of the French Society for Sleep Research and Medicine (SFRMS), which still supports the use of dopaminergic agonists for the most severe cases of RLS.
“For now, we have not updated the guidelines, but we are considering it,” said Chenini, referring to the new American recommendations.
Iron as First Line
According to the new AASM guidelines, intravenous iron supplementation is the preferred first-line treatment for severe RLS. In some cases, second-line antiepileptic drugs are considered a first-line treatment option in French recommendations when the severity is low.
These sensations of restlessness typically occur in the evening or at night during periods of rest or inactivity and are temporarily relieved by movement, such as walking and stretching. The condition often leads to repeated leg movements during sleep and difficulty falling asleep due to increased brain activity.
RLS is not fully understood but is often linked to problems with iron regulation.
MRI studies have shown iron deficiency in the brains of patients with RLS. This suggests a disruption in iron transport across the blood-brain barrier and into neurons, possibly due to a decrease in the transferrin receptor.
This disruption in iron regulation, believed to have a primarily genetic origin, induces an increase in the synthesis of dopamine and glutamate, which is likely the cause of the symptoms. In RLS, changes in the dopaminergic system are linked to risk factors such as aging and the use of certain medications.
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