Management of augmentation in patients with restless legs syndrome (RLS)*

* Augmentation is the main complication of dopaminergic therapy in RLS and refers to an overall increase in symptom severity with increasing doses of medication. It should be suspected in the following circumstances:

• A maintained increase in symptom severity despite appropriate treatment or following a dose increase, particularly if a dose reduction leads to an improvement in symptoms
• Earlier onset of symptoms in the afternoon/evening
• Topographic spreading of symptoms to previously uninvolved body parts (eg, arms)
• Shorter latency to symptom onset during the day when at rest
• Shorter duration of action of the drug

¶ Long-acting dopamine agonists include rotigotine patch, extended release pramipexole, and extended release ropinirole.
Δ Mild augmentation exists when all of the following criteria are met:

• Temporal shift in symptoms
• Dopaminergic dose does not exceed maximum recommended for RLS
• Symptoms cause no more than mild distress
• There has been no prior increase in dose above what was previously therapeutically effective

◊ Maximum recommended doses of dopamine agonists for RLS:

• Pramipexole 0.5 mg/day
• Ropinirole 4 mg/day
• Rotigotine 3 mg/day

§ At this juncture, some may choose to switch to a long-acting formulation or cross-titrate to a gabapentinoid (also known as alpha-2-delta ligands), rather than increase the total dopamine dose, in an effort to minimize or eliminate long-term dopamine exposure. Cross-titration refers to adding the new agent prior to or during the dopaminergic taper.
¥ Gabapentinoids include gabapentin enacarbil, pregabalin, and gabapentin. Relative contraindications to gabapentinoid therapy include obesity, risk of falls, and comorbid depression.
† Alternative to cross-titration is a 10-day washout with re-evaluation of need for ongoing treatment before introduction of a gabapentinoid or opioid. Patients may have severe RLS symptoms and profound insomnia during washout period. Low-dose long-acting opioids may be considered in patients with a relative contraindication to a gabapentinoid who have augmentation on a long-acting dopamine agonist.