What changed in the 2024 RLS treatment guidelines

For about twenty years, the standard first treatment for restless legs syndrome was a class of drugs called dopamine agonists: pramipexole, ropinirole, and the rotigotine patch. They often work well at first, and then cause problems over time for a large share of the people who take them.

In late 2024 the American Academy of Sleep Medicine (AASM) published new clinical practice guidelines and reversed that long-standing advice. Dopamine agonists are now conditionally recommended against as a routine first treatment for chronic RLS.

Augmentation

The reason for the change is a problem called augmentation. Over months or years on a dopamine agonist, many people find their restless legs get worse than before they started: symptoms show up earlier in the day, spread to the arms or trunk, and become more intense overall. For years this was often mistaken for the disease progressing on its own. It is now understood to be, in many cases, a side effect of the medication.

The new first-line treatments

The current first-line approach centers on two things:

• Iron. Checking iron status and correcting it when it is low. Common lab targets in the guideline are a ferritin above 100 ng/mL and a transferrin saturation above 20%.
• Alpha-2-delta ligands. A different class of medication (gabapentin, gabapentin enacarbil, and pregabalin) that does not carry the same augmentation risk.

Why many people haven't heard

Everyday practice often lags behind updated guidelines. Many people are still on a dopamine agonist, are slowly getting worse, and assume that is simply how the condition goes. If that describes you, it is worth asking your doctor whether the 2024 guideline applies to your situation.