Restless Legs Syndrome

With suitable pharmacotherapy, patients with any degree of restless legs syndrome (RLS) should be able to obtain substantial relief of symptoms. The best therapeutic success is attained when the physician tailors therapy to the patient's specific symptoms and can flexibly try a variety of agents, if needed. Therapy should be reserved for those in whom RLS cannot be managed with just sleep hygiene and related practices. It should not be withheld, however, if a patient reasonably believes that his or her quality of life is being impaired by RLS. The optimal initial approach to RLS in the general patient is usually the use of a dopaminergic agent: low-dose levodopa in milder cases, a dopamine agonist in more severe ones. Patients whose problems are primarily sleep related can initially be treated with a benzodiazepine. Patients who have symptoms primarily while awake can initially be treated with a dopaminergic agent or an opioid. Patients whose RLS discomfort is truly painful can initially be treated with gabapentin. Combination therapy with two or three agents from different classes can be useful as well. Determination of iron status is the most important initial laboratory evaluation in patients with RLS. Iron supplementation should be used as indicated. In the future, delivery modes other than oral administration of medications may be of significant benefit, especially in more severe cases.