French consensus: Pharmacoresistant restless legs syndrome

Dopaminergic agonists, α2δ ligands and opioids are, as single-drug therapy, the first line treatment for restless legs syndrome (RLS/Willis-Ekbom disease). However, despite treatment efficacy, exacerbations of RLS may occur with overall worsening in symptoms severity, development of pain and symptoms spreading to other parts of the body, without meeting augmentation syndrome criteria. This development of "drug-resistant" RLS can cause pain, severe insomnia and psychiatric disorders that affect considerably patients' quality of life. The lack of French recommendations for this form of RLS leave physicians with few options to help patients with physical and emotional distress. Our group of neurological experts and sleep specialists proposes a diagnostic and therapeutic strategy to provide better care and appropriate treatment through searching for the organic, psychiatric and/or iatrogenic causes of drug resistance. Once a drug-resistant RLS diagnosis has been confirmed, we recommend an obligatory work-up including: a video-polysomnogram, a biological evaluation including iron status, standard numeration and C-reactive protein level. Treatment will be comorbidity-dependent: dopaminergic agonist would be recommended in case of depression or associated periodic leg movements, α2δ ligand in case of insomnia, complaint of pain, or general anxiety, in association with low-dose opioids if necessary. Strong opioids should be preferred for multiresistant RLS.