Understanding Augmentation of RLS

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Restless legs syndrome (RLS) is a frustrating condition that involves an uncontrollable urge to move the legs, often accompanied by strange sensations, like crawling, pulling, or creeping in the legs. Fortunately, there are several treatment options for RLS, and most people can reduce their symptoms and improve their quality of life after making lifestyle changes or taking medications. However, for some people, symptoms can actually worsen after starting a medication or increasing the dose. This is called augmentation, and it’s one of the main reasons treatment fails in people with RLS. There are still a lot of things experts don’t understand about augmentation, like what exactly causes it. But there’s also a lot they do know. If you have RLS, it’s something you need to know about too.

There is a specific definition for augmentation

Augmentation is a worsening of RLS symptoms after starting a medicine or increasing its dose. It seems like the medicine is doing the opposite of what it’s supposed to do.

Doctors have known about augmentation for many years. But it wasn’t until 2007 that experts agreed on a formal set of criteria to diagnose it. If your doctor is evaluating you for RLS augmentation, he or she will ask you if:

  • Symptoms have an earlier onset in the day or night than at baseline 

  • Symptoms are more severe or intense than at baseline 

  • Symptoms start more quickly after a period of rest or inactivity

  • Symptoms spread to other body parts

If you also experience jerking or twitching as part of your RLS, this may intensify with augmentation as well. But you shouldn’t develop new symptoms. In other words, augmentation usually worsens existing symptoms, so it’s important to tell your doctor if new symptoms develop.

Augmentation primarily occurs with medicines that increase dopamine

Experts don’t fully understand what causes augmentation. But they do know it typically occurs with medicines that increase dopamine, called dopaminergic agents. Levodopa/carbidopa (Sinemet) tends to have the highest frequency, but pramipexole (Mirapex) and ropinirole (Requip) also cause it. It’s less of a problem with the rotigotine (Neupro) patch.

The risk of augmentation seems to increase with longer duration and higher doses of dopamine drugs. This has lead to experts to believe it may be the result of overstimulation of dopamine receptors. However, studies have also shown a link between augmentation and low iron levels. More research is necessary to study how and why it develops.

Preventing and treating augmentation takes a strategy

Augmentation most often develops within six months of starting or increasing the dose of a medicine. But it can occur in as little as a few weeks. Some strategies to prevent it include:

  • Delaying dopamine drugs for as long as possible

  • Using the lowest dose possible

  • Rotating dopamine drugs with other medicines to control symptoms

If your doctor suspects augmentation, he or she may recommend the following to see if your symptoms improve:

  • Discontinuing use of caffeine and alcohol

  • Measuring your blood iron levels and taking a supplement if necessary

  • Recommitting to regular moderate exercise and sleep habits

  • Stopping any medicines that can worsen RLS symptoms, such as sedating antihistamines

  • Undergoing a sleep study to rule out other sleep disturbances 

Your doctor may recommend reducing the dose or stopping your medicine to treat augmentation. Never do this on your own. Tapering dopamine drugs requires a doctor’s supervision to avoid serious side effects.
Your symptoms may worsen during the first few days of cutting back on your dopamine drug. This can be uncomfortable. Talk with your doctor and have a plan for using other medicines or non-drug strategies to manage your symptoms. This may include exercise and using massage, heat or cold to soothe your legs.

After taking a break from your medicine, your doctor may recommend trying a different dopamine drug. It’s not clear whether your risk of augmentation recurring is high with another dopamine drug or not. Many doctors feel it’s worth a try. Otherwise, your doctor may recommend other medicines including:

  • Gabapentin enacarbil (Horizant): the only non-dopamine drug FDA-approved to treat RLS

  • Anti-seizure medicines

  • Benzodiazepines

  • Narcotic pain relievers

The key takeaway is this—using dopamine drugs for RLS carries the risk of augmentation. Less than half of people who use a dopamine drug are able to continue it past five years. It’s important to work closely with your doctor to decide if a dopamine drug is right for you and to monitor for augmentation.

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Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2019 Oct 1
THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the site. If you think you may have a medical emergency, immediately call your doctor or dial 911.

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