Here are some research papers and book and website extracts that deal with augmentation, the link between iron and augmentation, and general diagnosis and treatment of WED/RLS:
Appropriate Use of Opioids in Treating RLS This first one is related to augmentation because the most effective treatments for the symptoms of augmentation and dopamine-agonist withdrawal are opioids.
Here's a link to the fulll text or you can download it here:
The 2021 Updated Algorithm (The Management of Restless Legs Syndrome: An Updated Algorithm). A comprehensive and up-to-date summary of the diagnosis and treatment of WED/RLS, including augmenation. Gives iron its proper place as front-line treatment.
2018 Consensus paper on treatment of refractory WED/RLS with opioids. Opioids are usually necessary to alleviate the extra-strong symptoms of withdrawal from a dopamine-type medication, and this paper explains to doctors why opioids are necessary and how to prescribe them.
The 2018 International RLS Study Group consensus guidelines on IRON TREATMENT for WED/RLS; notes that
iron infusions (IV iron treatments) are effective for moderate to severe disease in patients with
ferritin up to 300 ng/ml, and
oral iron in patients with
ferritin up to 75 ng/ml
2016 editorial: Restless legs syndrome (Willis-Ekbom disease): An urgent need for better treatments - Advises against using dopamine agonists to treat
augmentation in WED/RLS patients. From Sleep Medicine journal.
The RLS Foundation's brochures
1. Go to the
RLS Foundation website, and hunt around. Some publications are available for non-members.
2. Become a member, log in, click Member Portal at the top, click Publications in the drop-down list, and and scroll through. Some of the brochures are on augmentation:
- "A Quick Guide to Understanding and Managing Augmentation" is not very helpful - it has basic information that most doctors find online.
- "Medication Withdrawal after Augmentation" and "Understanding RLS and Augmentation - Frequently Asked Questions" taken together are probably the best of the brochures.
- "Augmentation: Diagnosis and Treatment" is also pretty good. Note, however, that even though it is technically true that augmentation "typically" takes months to develop, it can happen within days.
3. Scroll farther to Information for Healthcare Providers. The
2021 RLS Medical Bulletin is probably the best single resource to download if you only want to get one.
If you are not a member, go to
http://www.rls.org/ and click Join or Renew - the red box at top right.
If you are broke and the small membership fee, which goes to support research as well as creation of these documents, is too much, you can email the Foundation about getting a scholarship (free) membership:
info@rls.org or (507) 287-6465. It's worth it, to access these and other Foundation publications.
From the Johns Hopkins Center for RLS website, a good description of the role of iron in RLS/WED; recommends raising
ferritin to over 100 & trying
iron infusions:
This research paper shows that augmentation due to dopamine medications is very common:
This research note emphasizes that the incidence of augmentation in people being treated with dopamine agents increases over time:
ARCHIVED
- Extract from Clinical Management of Restless Legs Syndrome, 2nd edition, Treating Augmentation section, by Lee, H.B., Buchfuhrer, M.J., Allen, R. and Hening, W.A., 2013 (Professional Communications Inc., USA), p.181-183; treating augmentation and the use of potent opioids: This book also has the new recommended maximum daily doses of 0.25 mg for pramipexole on p.161-2 & p. 242, and 1.0 mg for ropinirole on p.164 & p. 242. This mulit-authored book would be a good choice to show your doctor.
- Buchfuhrer's 2012 paper: an excellent review of WED/RLS treatment, including lower recommended maximum daily doses for dopamine agents (0.25 mg for pramipexole, 1.0 mg for ropinirole), a cautionary note about impulse control disorder, treatment of augmentation, benefits of opioids, use of IV iron, combination and rotation of medications, and a recommendation to keep ferritin over 75 ng/ml: Citation: Buchfuhrer, Mark J., Strategies for the Treatment of Restless Legs Syndrome; Neurotherapeutics (2012) 9:776-790
- A magazine-style summary of Buchfuhrer's views (see above), from a 2015 issue of in Sleep Review Magazine:
- The International RLS Study Group's 2015 white paper on AUGMENTATION prevention and treatment, with recommendations to keep ferritin over 50 or 75 ng/ml and transferrin saturation above 20%, and use of opioids in severe cases:
- This research paper shows that low ferritin is associated with greater RLS/WED symptom severity and increased risk of augmentation: This report was the first to confirm the association between low ferritin and greater chance of augmentation on dopamine agonists.
- This report from the International RLS Study Group recommends that serum ferritin be at least 75 ng/ml:
Edited for readability -Beth Apr 2014
Edited to add Augmentation extract -Beth Jan 2015
Edited to add IRLSSG 2015 white paper & note about free Foundation augmentation brochure -Beth Oct 2015
Edited to update links & improve readability -Beth June 2016
Edited to add 2016 editorial & to accommodate new RLS.org website -Beth Mar 2017
Edited to add Sleep Review Magazine & extra info for other papers - Beth Sep 2017
Edited to add 2018 Iron Guidelines - Beth Oct 2018
Edited to re-attach all documents, which got lost in the server move - Beth Aug 2020
Edited to add the 2018 consensus paper on opioid treatment, so I wouldn't have to keep looking for it - Beth, Jan 2021
Edited to add the 2021 Updated Algorithm and moved some items to new Archived section - Beth, Oct 2021
Edited to change 2017 to 2021 version of the Foundation's RLS Medical Bulletin for Healthcare Providers -Beth, Dec 2021
Edited to add the Opioid paper - Beth, Nov 2022