A one-page restless legs syndrome summary for your doctor

RLS de-prescribing plan — one-page summary for the treating physician

Prepared by the patient from docs/SOLUTION_PROTOCOL.md (full citations, evidence grades) and docs/SOLUTION_VERIFICATION.md (citation audit). Not a prescription. Every step below is a request for your assessment, not a decision already taken.

Medical disclaimer. RLS is a chronic neurological condition; no cure is claimed anywhere in this document, only reduced or, where evidence supports it, eliminated medication need in a subset of patients. This summary is not individual medical advice and does not substitute for the treating physician's own judgement. Any change to dopamine-agonist or alpha-2-delta dosing must occur only under physician supervision and a dopamine agonist must never be stopped abruptly (Section 3.6, Section 4). Full grading and citations: docs/SOLUTION_PROTOCOL.md.

Grades: A = meta-analysis / ≥2 RCTs · B = single RCT or large cohort · C = small or observational · D = guideline consensus · E = mechanistic.

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1. The patient's request

Adult with IRLSSG-confirmed chronic-persistent RLS on daily dopaminergic or alpha-2-delta therapy, asking to: (a) be assessed for augmentation against the Max Planck criteria; (b) have iron status corrected first (ferritin and TSAT); (c) have aggravating co-medication reviewed; and (d) if augmentation is confirmed or medication burden is unacceptable, undertake a physician-led, never-abrupt transition off the dopamine agonist. The patient explicitly accepts that staying on medication may be the right outcome.

2. Guideline basis

3. Proposed sequence

3.1 Diagnosis and baseline. Re-confirm all five IRLSSG criteria; exclude neuropathy, cramps, akathisia, venous disease. Record baseline IRLS (0–40) and the symptom-onset clock time — the reference for all future augmentation assessment. Score against Max Planck criteria (a ~4-hour advance in onset is the single best criterion; PMID 17544323, D) and consider ASRS (PMID 17543579, B).

3.2 Labs. Ferritin + TSAT (morning, ≥24 h off oral iron); CBC, eGFR, B12, folate, TSH, HbA1c as comorbidity/mimic screening (D). Serum phosphate before and after any FCM course. Vitamin D is not a treatment target in RLS — dedicated RCT negative (PMID 30430372, B; 39064758, A).

3.3 Aggravator review (highest yield, lowest risk; A/B). Mirtazapine and quetiapine account for

80% of drug-induced RLS in 340,099 monitored inpatients (PMID 42251748, B); metoclopramide (23456369, C); PPIs in two national cohorts, H2 antagonists in one (33119070, B). Bupropion is the best-evidenced antidepressant substitute (28822709, A); SSRIs need no blanket ban (32546134, C). Ask about OTC melatonin (20226733, C, n=8 unblinded).

3.4 Iron repletion — before any taper (A efficacy, D thresholds). Oral: ~65 mg elemental, alternate-day single morning dose (29032957, B). IV FCM 1000 mg total: IRLS −8.0 vs −4.8 (38625730, B); −11.9 vs −7.88 with 37.5% medication-free at 30 weeks (27823710, B); pooled WMD −6.03 (39326219, A). 500 mg failed (29458749, B) — suggesting, by cross-trial comparison only, 1000 mg as the minimum effective total dose. Rationale for iron-first: rescue-medication use 32.7% vs 59.4% (p=0.0002, NNT ≈4) in the protocolised-taper RCT (38625730, B). Judge at week 12, not week 4 (28643901, B). Stop-rule: phosphate <2.0 mg/dL (50.8% incidence vs 0.9% ferumoxytol; 30518682, B, non-RLS anaemia population), bone pain or proximal weakness → stop FCM, correct phosphate, consider ferric derisomaltose for repeated courses.

3.5 Bridge / destination — add before you subtract (D, safety-driven). Establish the replacement at an effective dose before any agonist reduction (35609673, D).

• Destination: alpha-2-delta ligand. Pregabalin 300 mg vs pramipexole 0.5 mg, augmentation 2.1% vs 7.7% over 40–52 weeks (24521108, B) — report alongside the 6 suicidal-ideation cases on pregabalin vs 2–3 on pramipexole. Gabapentin enacarbil 1200 mg, CGI-I 77.5% vs 44.8%, NNT ≈3 (21677899, B); no EMA authorisation (31229171, D).
• Intermediate: rotigotine cross-titration, 85% switch success at 5 weeks but 50% retention at 12 months and rotigotine augments too (27810181, C).
• Reserved: prolonged-release oxycodone-naloxone, IRLS −16.5 vs −9.4 (24140442, B), per appropriate-use consensus (29304922, D).

3.6 Taper schedule — the honest position. No RCT has compared taper rates, and no guideline in this knowledge base gives a numeric schedule. The 2016/2018 IRLSSG documents describe qualitative moves only (divide, advance, switch class); the Mayo algorithms explicitly state no mg/day rate. The widely circulated "10–25% every 2–4 weeks" rule could not be traced to any source and is not asserted here. The one structured protocol with published outcomes (rapid taper + iron + alpha-2-delta up-titration over one month) achieved complete discontinuation in 77% (24/31), IRLS 27.1→15.1, failure predicted by longer prior augmentation (11.4 vs 3.5 years, p=0.003) — single centre, uncontrolled, n=31 (42673880, C). Decrement size and interval are yours to set.

3.7 Monitoring. IRLS at baseline, weeks 6/12/24, then 6-monthly (a change <6 points is inside the −6.58-point pooled placebo band; 28490647, A / 24051118, C). Daily diary with onset clock time. Ferritin + TSAT 8–12 weeks post-course. Phosphate around weeks 2 and 5 post-FCM. ICD, mood/suicide risk, falls and driving at every visit and every dose change.

4. Red flags

• Suicidal ideation / self-harm — RLS aHR 2.66 (95% CI 1.70–4.15; 31441941, B); risk concentrates during taper-related worsening. Do not taper during acute psychiatric crisis.
• DAWS — anxiety, panic, dysphoria, orthostatic hypotension, craving; resists dopaminergic rescue, no proven treatment, can last months. RLS-specific incidence unquantified (the "up to 24%" figure is from PD cohorts; 23686524 / 41870480, D).
• Impulse control disorder — 7.1% (10/140) in a mixed agonist/levodopa cohort, 8/10 on an agonist (21955669, C); 10% at 8 years with 42% augmentation (23036265, C). May persist post-withdrawal.
• Gabapentinoid + opioid — dizziness OR 3.26, cognitive dysfunction OR 3.13, respiratory depression OR 1.71 (1.31–2.24), mortality OR 2.76 in non-randomised data only (36304170, A); falls aHR 1.18 (35476819, B, non-RLS cohort). 2019 FDA respiratory warning active (33728039, D).
• Renal impairment — gabapentin t½ 5–9 h → up to 132 h in dialysis; severe but reversible neurotoxicity without aggressive renal adjustment (36518357, E).
• Sleep attacks while driving — 10% self-reported in long-term pramipexole users (23036265, C).
• New neurological signs — RLS precedes PD, OR 4.19 (3.91–4.50) any prior diagnosis, OR 3.73 (3.39–4.09) at a 5–10-year lag (36342675, B).
• Never: stop abruptly · raise the agonist to relieve worsening · reduce before the replacement works · add a second dopaminergic agent · judge iron at 4 weeks.

5. Key references

39324694 (AASM) · 34218864 / 42203073 (Mayo/IRLSSG algorithms) · 27448465 (augmentation guideline) · 29425576 (IRLSSG iron) · 39501372 + AWMF 030/081 (DGN/DGSM) · 25023924 (diagnostic criteria) · 17544323 (Max Planck) · 17543579 (ASRS) · 38625730 / 27823710 / 29458749 / 28643901 / 39326219 / 30609006 (iron) · 30518682 (FCM hypophosphataemia) · 24521108 / 21677899 (alpha-2-delta) · 24140442 / 29304922 (opioid) · 27810181 (rotigotine cross-titration) · 42673880 / 35532181 (withdrawal cohorts) · 23686524 / 41870480 (DAWS) · 21955669 / 23036265 (ICD, driving) · 36304170 / 35476819 / 33728039 (combination safety) · 36518357 (renal) · 31441941 (suicide risk) · 36342675 (PD prodrome) · 28490647 / 24051118 (placebo band, MCID) · 42251748 / 33119070 / 28822709 (aggravators) · 37458698 / 41581285 (TOMAC) · 21725862 (natural history).

Full text and grading for each: docs/SOLUTION_PROTOCOL.md §7.