Management of treatment failure in restless legs syndrome (Willis-Ekbom disease)

Treatment of existing augmentation should be initiated, where possible, with the elimination/correction of extrinsic exacerbating factors (iron levels, antidepressants, antihistamines, etc.). In cases of mild augmentation, dopamine agonist therapy can continue by dividing or advancing the dose, or increasing the dose if there are breakthrough nighttime symptoms. Alternatively, the patient can be switched to an α2δ ligand or rotigotine. For severe augmentation, the patient can be switched to an α2δ ligand or rotigotine, noting that rotigotine may produce augmentation at higher doses with long-term use. In more severe cases of augmentation an opioid may be considered, bypassing α2δ ligands and rotigotine.