The 2025 AASM restless legs guideline, explained

The guideline is "Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine clinical practice guideline" by Winkelman JW, Berkowski JA, DelRosso LM and colleagues, published in the Journal of Clinical Sleep Medicine (2025;21(1):137–152; DOI 10.5664/jcsm.11390; PMID 39324694). It is often cited as the 2024 guideline because it appeared online in 2024.

An AASM-commissioned expert task force reviewed the treatment literature with the GRADE method and turned it into graded good-practice statements and treatment recommendations. Under this site's evidence rubric, a guideline is grade D (guideline or expert consensus), and the badge below shows that grade. Individual recommendations inside it carry their own certainty ratings, quoted where relevant.

The guideline's first statement is a good-practice statement: clinicians should routinely test serum ferritin and transferrin saturation (TSAT) in all patients with clinically significant restless legs syndrome, whether or not the person is anaemic. The thresholds that decide what happens next are in the table.

These cut-offs are explicitly different from the ones used for the general population. A plausible reason is that iron in the brain and iron in the blood can diverge: in idiopathic RLS, spinal-fluid ferritin has been found reduced even though serum ferritin and transferrin were normal. That is why a ferritin result that a laboratory labels "normal" can still fall in the range where the guideline advises iron. This is the field's working model, not a settled fact; the largest brain-MRI study did not confirm lower brain iron.

Who orders the tests and who decides on iron is a matter for the treating physician. Do not start high-dose iron on your own: both oral and IV iron should follow laboratory results.

For iron itself, the guideline makes a strong recommendation for IV ferric carboxymaltose in people with appropriate iron status, rated moderate certainty of evidence. It is the only iron formulation whose AASM recommendation this site's knowledge base has summarised, so it is the only one described here.

Which iron route fits a given person, and how it is monitored, is the prescriber's decision. See the iron therapy synthesis for the trial evidence behind IV and oral iron.

The guideline gives strong recommendations for three alpha-2-delta ligands: gabapentin enacarbil, gabapentin and pregabalin. Across recent guidelines this class is the most consistently endorsed first-line drug group, mainly because of a lower augmentation risk than dopamine agonists.

The dose, the timing and whether a medicine suits a particular person are set by the prescriber. These drugs are themselves long-term medications, not a drug-free endpoint, and they should be started, adjusted or stopped only with a physician.

The guideline gives a conditional recommendation against the standard use of pramipexole, ropinirole and rotigotine because of augmentation, the drug itself gradually making symptoms worse. It gives a strong recommendation against cabergoline, on grounds of cardiac valve damage.

Not every country agrees yet. The 2024 German guideline still lists non-ergot dopamine agonists alongside gabapentinoids as first-line, and in a survey of national sleep societies the recommendations against dopamine agonists were the main point of regional disagreement.

If you already take a dopamine agonist, do not stop it on your own. Tapering is always physician-supervised and never abrupt, because stopping suddenly can cause severe withdrawal symptoms. The pages below explain augmentation and how a supervised plan is built.

According to this site's knowledge base, the guideline also gives three conditional recommendations in favour. For opioids, it suggests extended-release oxycodone and other opioids over no opioids (moderate certainty). For dipyridamole, it suggests use over none (low certainty), and this is the one AASM recommendation a survey of national sleep societies did not find supported internationally. For bilateral high-frequency peroneal nerve stimulation, it suggests use over none.

Opioids are not a non-drug option; most guideline traditions treat them as a physician-supervised bridge for difficult cases.

The guideline covers more than this list, including levodopa and other medicines. The knowledge base has not yet summarised the direction of those recommendations, so they are not stated here. Read the full guideline (link below) for them.

The 2012 AASM practice parameters rated pramipexole and ropinirole STANDARD, the highest level. They listed iron only as an OPTION for people with low ferritin; the knowledge base's summary of that document records no specific ferritin cut-off. The 2016 American Academy of Neurology guideline still rated pramipexole, rotigotine, cabergoline and gabapentin enacarbil Level A, while flagging augmentation risk.

The 2025 AASM guideline reverses the dopamine agonist position within the same organisation: conditional against standard use of pramipexole and ropinirole, driven by accumulated augmentation evidence over 13 years rather than new data on whether the drugs work. It also formalises the ferritin and TSAT thresholds above, and gives alpha-2-delta ligands strong recommendations.

Most individual recommendations are graded conditional, with low-to-moderate certainty of evidence, which reflects a thin randomised-trial base for many treatments, especially in kidney-failure and paediatric groups. The guideline reflects the literature up to its review cut-off.

A 2025 World Sleep Society survey of national societies found 12 of the 20 AASM recommendations fully supported internationally and 5 partially supported. A guideline is expert consensus, not individual medical advice: your own treatment belongs in a conversation with your physician.

The complete guideline, with every recommendation, remark and certainty rating, is published in the Journal of Clinical Sleep Medicine.