Фонд борьбы с синдромом беспокойных ног обновил алгоритм лечения и ввел новые методы

The update translates recent evidence and expert consensus into practical guidance for managing restless legs syndrome. By Sree Roy So much has changed in the management of restless legs syndrome (RLS) in just the last few years that the Restless Legs Syndrome (RLS) Foundation’s scientific and medical advisory board published an updated treatment algorithm in May 2026, replacing its 2021 version. Published in Mayo Clinic Proceedings, it is a practical guide for clinicians (from sleep specialists to primary care physicians). The new algorithm arrives just over a year after the American Academy of Sleep Medicine (AASM) released its own clinical practice guideline on RLS treatment. While very similar, the RLS Foundation algorithm is designed to be a practical, hands-on guide that builds upon the AASM’s more methodologically rigid framework. “The algorithm we’ve produced is not meant to supersede or compete with the AASM guideline,” says RLS Foundation algorithm lead Michael H. Silber, MB, ChB, a consultant in the department of neurology at Mayo Clinic. “It is meant to complement and extend it.” John W. Winkelman, MD, PhD, a co-author of both the RLS Foundation and the AASM papers, says sleep physicians should reach for one or both of these updated papers; however, do not rely on outdated papers or knowledge from 10 or even five years ago. “The important point is these two guidelines are quite distinct from previous authorized guidelines for the treatment of RLS,” says Winkelman, chief of the Sleep Disorders Clinical Research Program at Massachusetts General Hospital. The biggest change in both the AASM and the RLS Foundation papers—which are available for free in their entirety via PubMed—is that dopamine agonists are no longer recommended as first-line therapy for RLS. As a courtesy, Sleep Review provides key takeaways from the new RLS Foundation algorithm below. 1. RLSF Is the Practical Companion to AASM’s Guideline Clinicians should view the two recent RLS papers as complementary tools. The 2025 AASM guideline was developed using the rigorous GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, which constrains recommendations primarily to evidence from randomized controlled trials. While this provides a strong evidence base for individual treatments, it doesn’t necessarily offer a clear pathway for day-to-day clinical decision-making. The RLS Foundation algorithm, in contrast, was developed through a more informal consensus process that incorporates long-term follow-up studies and extensive clinical experience alongside controlled trials. This allows it to address practical challenges not covered by the AASM guideline, such as how to manage augmentation. “What we try to do in the algorithm is provide a much more detailed, practical guide of how to treat restless legs: what to use first, what to use second, when should you use them, what are the advantages and disadvantages in comparison of different agents,” Silber says. 2. Stop Prescribing Dopamine Agonists as First-Line Therapy The most significant shift in RLS management is the move away from dopamine agonists as a first-line treatment for RLS. The drugs were well-established as the standard of care, but growing evidence of augmentation—a paradoxical, drug-induced worsening of RLS symptoms over time—has changed the recommendation. “For 20 years, dopamine agonists have been the reflexive first-line therapy for RLS,” Winkelman says. “That reflexive use of dopamine agonists is something we would like to change, given the balance of long-term side effects and short-term efficacy.” The algorithm states that augmentation occurs in 42% to 70% of patients treated with dopamine agonists over eight to 10 years. The algorithm now firmly places gabapentinoids (gabapentin, gabapentin enacarbil, and pregabalin) and iron therapy as the first-line treatments. Dopamine agonists should only be considered if these first-line agents fail or are not tolerated, and only after a thorough discussion with the patient about the risks. “I hope these will be very clear recommendations, so we can get away from the ease of writing a quick prescription for a dopamine agonist. And when the patient calls and says, ‘you know, it’s not working as well as it did before,’ automatically increasing the dose—which is the worst thing that can happen,” Silber says. 3. Consider IV Iron for Baseline Serum Ferritin Up to 300 µg/L The RLS Foundation algorithm broadens the criteria for considering intravenous (IV) iron therapy, a difference from the 2025 AASM guideline, which suggests IV iron for patients with a serum ferritin level up to 100 µg/L. The new algorithm recommends IV iron be considered for any patient with chronic persistent RLS with a serum ferritin level up to 300 µg/L and a transferrin saturation (TSAT) below 45%. This change is based on emerging evidence and a deeper understanding of iron’s role in the brain. “Serum ferritin does not correlate with iron stores in the brain,” Silber explains, adding that ferritin levels can fluctuate and that lab assays vary. Most importantly, he notes, recent studies suggest that patients with ferritin levels between 100 and 300 µg/L respond just as well to IV iron as those with levels below 100 µg/L, without a significant risk of hepatic iron overload as long as the TSAT is below 45%. This expanded indication gives clinicians another powerful tool for managing RLS, especially since oral iron is poorly absorbed once serum ferritin concentrations exceed 75 µg/L. 4. Identify and Manage RLS Augmentation Better Because many patients are still on long-term dopamine agonist therapy, clinicians will inevitably encounter augmentation. The algorithm provides a practical guide to recognizing and managing it—a topic the AASM guideline did not address in detail. “The RLSF decided that this was a major gap,” Winkelman says. The first step is recognition. Augmentation should be suspected in any patient on a dopamine agonist whose symptoms are worsening. Key signs include symptoms appearing earlier in the day, spreading to the arms or other body parts, and having a shorter duration of action. The algorithm stresses a critical rule: never increase the dopamine agonist dose to treat augmentation symptoms. “If you find yourself in a hole, stop digging,” Winkelman says. Management requires a slow, careful weaning of the dopamine agonist, often after starting an alternative agent like a gabapentinoid or, more commonly, a low-dose opioid. Patients must be educated about a temporary worsening of symptoms during the weaning process. The goal is to discontinue the dopamine agonist completely, as reintroduction will likely cause augmentation to return rapidly. 5. Consider Low-Dose Opioids If First-Line Therapies Fail The algorithm elevates the role of low-dose opioids, positioning them as a key therapeutic option for patients who do not respond to or tolerate iron and gabapentinoids. “No longer are low-dose opioids only indicated for highly refractory restless legs,” Silber says. “They now should seriously be considered for people who failed the first-line agents.” When first-line treatments are exhausted, the choice between a dopamine agonist and a low-dose opioid requires a frank, shared decision-making conversation. “Each of them has baggage,” Winkelman says. Opioids carry stigma and regulatory hurdles, while dopamine agonists carry the high risk of augmentation. However, the algorithm notes that for RLS, the risk of tolerance and dependence with low-dose opioids is low, with the vast majority of patients remaining on a stable dose long-term. 6. Employ Shared Decision-Making Throughout the document, the authors emphasize the importance of shared decision-making. This is particularly crucial when considering second- and third-line therapies, where the risk-benefit profiles become more complex. “At each stage, we want to emphasize that decisions should be jointly made by knowledgeable clinicians and informed patients,” Silber says. This involves educating the patient on the long-term risks of dopamine agonists, including both augmentation and impulse control disorders, as well as discussing the potential side effects and stigma associated with opioids. 7. Consider Adding On Peroneal Nerve Stimulation The algorithm includes bilateral high-frequency peroneal nerve stimulation, an FDA-approved nonpharmacological treatment for patients with moderate to severe RLS who have failed at least one medication. The wearable device stimulates the peroneal nerves, which is thought to mimic the voluntary movements that relieve RLS symptoms. Clinical experience suggests it is a useful adjunctive therapy. “Most of the people who are using it in my practice are applying it in the middle of the night when they may have symptoms when they wake up,” Winkelman says. “And I’d say 50% get a benefit, maybe enough to be able to fall asleep without having to take more medicine.” Silber also has been prescribing peroneal nerve stimulation to patients who have failed at least one medication. ”It’s been a useful addition,” he says. “Whether it will be useful as a primary treatment, I don’t know. It’s only FDA-approved for patients who fail at least one medication, and they’re usually on other medications at the time.” References 1. Silber MH, Berkowski JA, Buchfuhrer MJ, et al; Scientific and Medical Advisory Board of the Restless Legs Syndrome Foundation. An Updated Algorithm for the Management of Restless Legs Syndrome. Mayo Clin Proc. 2026 May 26:S0025-6196(26)18546-2. 2. 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. 2025 Jan 1;21(1):137-52.