EAN 2025 | The diagnosis and treatment of RLS: updated guidelines

This is a large group of conditions, so I focus mainly on restless legs syndrome, which is a very common condition affecting around 10% of the population in Europe. Also, about 2-3% require treatment, so in some cases it is less severe. And in this case, an accurate clinical diagnosis is important. So the diagnosis is only based on the clinical assessment, but this needs to be accurate. And you need, of course, to be aware of the diagnostic criteria. You can also have some supportive criteria, but the clinical part is the most important one. For other sleep-related movement disorders, you also need video polysomnographic confirmation, but these are more rare conditions. So the main focus of my talk, I’ve touched briefly on other sleep-related movement disorders, but of course, restless legs syndrome, because this is a neurological meeting, and any neurologist sees actually patients with restless legs syndrome, because it’s so common. For most of these minor sleep-related or more sleep-related movement disorders, unfortunately we would still need much more data about treatment. There’s no good guideline because just we do not have any good clinical trials assessing treatment. But there are these current results in some other conditions like nocturnal leg cramps is also part of this group of sleep-related movement disorders. and even in this common condition we do not have enough good clinical trials for a best practice guideline. For what concerns restless leg syndrome, we have guidelines. There are still guidelines which are a bit older from the International RLS study group. There was a recent update at the end of last year by the American Academy of Sleep Medicine and European guidelines are in preparation with the participation of different societies including the European Academy of Neurology, the European Sleep Research Society, the European RLS Study Group, the European Paediatric Neurological Association and the European MDS Society, European Section and also Patients’ Representatives. This is however a long process, it’s ongoing because of course you need to review the current literature to make a recommendation and we will try with these guidelines also I’m involved in this preparation also to provide good treatment algorithms for RLS and also to address a specific population for example people with kidney disease because the incidence of RLS is more frequent or people with neurological conditions like Parkinson’s disease. The main change from the recent guidelines by the American Academy of Sleep Medicine was a conditional recommendation against all dopaminergic treatments. Also, practitioners are allowed to use this medication in case the patient possesses more value on the short-term efficacy compared to long-term side effects. And the reason is that these medications are really effective, but on the long term they are related to a very high risk of developing the so-called augmentation, which is a paradoxical worsening of symptoms related to treatment. So that patients have the feeling they always need to increase the dosage because the symptoms get worse, but actually increasing the dosage, symptoms get even worse and you have an improvement if you reduce the dose. And then it’s a condition that it’s really hard to treat and it seems also that patients can respond less to different medications. So one of the main aims of treating RLS is also to avoid the development of augmentation.

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