A Paradigm Shift: Latest (2024) American Academy of Sleep Medicine Guidelines for Restless Legs Syndrome and Periodic Limb Movement Disorder

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J Sleep Med. 2024;21(3):164-165
Publication date (electronic) : 2024 December 31
doi : https://doi.org/10.13078/jsm.240025
Shree Krishna Hospital, Pramukhswami Medical College, Bhaikaka University, Anand, India
Address for correspondence Nimit Khara, MD Shree Krishna Hospital, Pramukhswami Medical College, Bhaikaka University, Karamsad, Anand, Gujarat 388325, India Tel: +91-9898325093, E-mail: drkhara@gmail.com
Received 2024 November 22; Accepted 2024 December 9.

Dear Editor,

The 2024 American Academy of Sleep Medicine (AASM) guidelines for restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) introduce significant updates in diagnostic and therapeutic approaches, reflecting the latest research on sleep-related movement disorders. Compared with the 2012 guidelines, the revisions emphasize long-term safety, patient-centered care, and evidence-based practices to improve clinical outcomes and quality of life.

One of the most notable updates is the prioritization of iron studies as standard diagnostic measures. Regular ferritin and transferrin saturation testing is recommended for all patients with clinically significant RLS, with intervention thresholds set at ferritin levels below 75 ng/mL and transferrin saturation below 20% [1]. This differs from previous guidelines, in which iron deficiency was acknowledged but not rigorously evaluated. Studies highlighting the relationship between brain iron deficiency and RLS pathophysiology have driven this shift, with intravenous (IV) ferric carboxymaltose receiving strong support in cases of moderate iron deficiency [2].

Pharmacological treatments have also undergone significant changes, particularly regarding the use of dopamine agonists. Previously considered first-line therapies such as pramipexole and ropinirole are now conditionally recommended because of their association with augmentation worsening of RLS symptoms over time and impulse control disorders [3]. This marks a shift towards safer alternatives, with gabapentinoids such as gabapentin, enacarbil, and pregabalin now positioned as first-line treatments. These drugs have demonstrated sustained efficacy in reducing symptom severity, improving sleep quality, and minimizing long-term risks [4]. Opioids, such as extended-release oxycodone, are reserved for refractory cases, with careful attention paid to the risks of dependence and overdose.

In addition to pharmacological treatments, these guidelines emphasize non-pharmacological interventions. Lifestyle modifications, including avoiding exacerbating factors, such as caffeine and alcohol, maintaining regular exercise, and adhering to sleep hygiene practices, are strongly encouraged. Cognitive behavioral therapy for insomnia has also been highlighted as an effective adjunct therapy, reflecting its utility in addressing the common comorbidities of sleep disturbance in patients with RLS.

The updated guidelines align with but diverge from European and other international recommendations. European guidelines continue to endorse dopamine agonists as first-line treatment for mild-to-moderate RLS, albeit with close monitoring of augmentation [5]. The AASM de-emphasizes the importance of these agents, reflecting greater caution. Both sets of guidelines support iron supplementation; however, the AASM uniquely promotes IV iron formulations for moderate deficiencies, as supported by recent clinical trials. Differences in device-based therapies are also notable, with AASM providing conditional support for high-frequency peroneal nerve stimulation as a novel intervention for refractory RLS cases.

The 2024 AASM guidelines represent a paradigm shift prioritizing long-term safety and individualized care while integrating advances in RLS research. By focusing on alternatives to dopamine agonists and incorporating robust iron management protocols, the recommendations aim to reduce treatment-related risks and enhance the quality of life of the affected patients. These updates underscore the need for clinicians to balance patient preferences, clinical efficacy, and safety when managing RLS and PLMD.

Notes

The author has no potential conflicts of interest to disclose.

Funding Statement

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Acknowledgements

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References

1. Winkelman JW, Berkowski JA, DelRosso LM, et al. Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2024 Sep 26 [Epub]. https://doi.org/10.5664/jcsm.11390.
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3. Garcia-Borreguero D, Silber MH, Winkelman JW, et al. Guidelines for the first-line treatment of restless legs syndrome/Willis-Ekbom disease, prevention and treatment of dopaminergic augmentation: a combined task force of the IRLSSG, EURLSSG, and the RLS-foundation. Sleep Med 2016;21:1–11. https://doi.org/10.1016/j.sleep.2016.01.017.
4. Garcia-Borreguero D, Larrosa O, de la Llave Y, Verger K, Masramon X, Hernandez G. Treatment of restless legs syndrome with gabapentin: a double-blind, cross-over study. Neurology 2002;59:1573–1579. https://doi.org/10.1212/wnl.59.10.1573.
5. Garcia-Borreguero D, Ferini-Strambi L, Kohnen R, et al. European guidelines on management of restless legs syndrome: report of a joint task force by the European Federation of Neurological Societies, the European Neurological Society and the European Sleep Research Society. Eur J Neurol 2012;19:1385–1396. https://doi.org/10.1111/j.1468-1331.2012.03853.x.

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