Restless legs syndrome Management Ferrous sulfate and vitamin C Q Is serum ferritin 75 mg/L? Yes Consider ferrous sulfate with vitamin C to alleviate symptoms in patients with RLS and serum ferritin 75 mg/L. C No Patients with end-stage renal disease Q Does the patient have end-stage renal disease on hemodialysis? Yes Consider vitamin C and E supplementation (alone or in combination) as first-line treatment in patients with secondary RLS associated with end-stage renal disease on hemodialysis. C Consider ropinirole, levodopa, or exercise as treatment options in patients with secondary RLS associated with end-stage renal disease on hemodialysis. C No Patients with periodic leg movements of sleep Q Does the patient have periodic leg movements of sleep? Yes Consider one of the following agents in patients with RLS and periodic leg movements of sleep: ropinirole B pramipexole, rotigotine, cabergoline, or pregabalin C levodopa C No Patients with insomnia Q Does the patient have insomnia? Yes Consider using a pharmacologic agent that improves objective or subjective sleep parameters in patients with primary RLS and insomnia. Consider using gabapentin or cabergoline as first-line treatment agents to improve subjective measures of sleep. B Consider using ropinirole, gabapentin, or pregabalin as treatment options to improve measures of objective sleep (e.g. sleep efficiency, sleep latency, and wakening after sleep onset). C No Patients with psychiatric symptoms Q Does the patient have concomitant anxiety or depression? Q Does the patient have restless leg syndrome-related mood disturbances? Yes to any Consider ropinirole in patients with RLS and concomitant anxiety C or concomitant depression C Consider gabapentin to improve overall mood in patients with RLS. C Consider pramipexole in patients with moderate-to-severe mood disturbances related to RLS. C No to all Consider pramipexole or rotigotine as first-line agents for the treatment of RLS, based on strong evidence. B Consider levodopa as a treatment option for patients with RLS, based on weak evidence. C Device therapy Consider pneumatic compression devices, initiated before symptom onset, in patients who desire nonpharmacological approaches to treatment of RLS. C Consider near infrared light therapy or repetitive transcranial magnetic stimulation. C