Insights From the 2026 Restless Legs Syndrome Foundation Algorithm: Michael Silber, MBChB

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“For chronic, persistent restless legs, iron should be thought about first, with gabapentinoids if iron alone is ineffective, and then carefully considered options such as low-dose opioids, limited dopamine agonist use, and peroneal nerve stimulation, all within a shared decision-making framework.”

Restless legs syndrome (RLS) remains a common yet challenging neurologic condition to manage, particularly in patients with chronic, persistent symptoms that significantly disrupt sleep and quality of life. Evolving evidence has highlighted the importance of reassessing traditional treatment hierarchies, especially around iron status, gabapentinoids, dopaminergic therapies, and the emerging role of neuromodulation.¹ Clinicians are increasingly tasked with balancing efficacy, safety, and long-term tolerability, while also navigating issues such as augmentation, opioid stewardship, and patient concerns about dependence and adverse effects.

At the recently concluded 2026 SLEEP Annual Meeting, held June 14-17 in Baltimore, Maryland, Michael Silber, MBChB, sleep medicine specialist at Mayo Clinic, presented a session titled “Conversations and Controversies in RLS Management: Insights from the 2026 RLS Foundation Algorithm.”² In his talk, Silber discussed the updated 2026 algorithm for the management of RLS, published in Mayo Clinic Proceedings.¹ This latest iteration synthesized an extensive review of the literature and cumulative clinical experience to provide practical, stepwise guidance for clinicians treating RLS in routine practice, with particular focus on chronic, moderately severe disease.

In an interview with NeurologyLive^®, Silber outlined key takeaways from the algorithm-based approach to RLS management. He emphasized the need to systematically assess iron status in all patients with chronic, persistent RLS and to consider intravenous iron when appropriate. In addition, Silber described the evidence and rationale for low-dose opioid therapy, including buprenorphine, as a standard option in carefully selected patients. Furthermore, he reviewed the constrained but persistent role of dopamine agonists under strict dosing and monitoring to mitigate augmentation, and highlighted high-frequency bilateral peroneal nerve stimulation as an emerging neuromodulation strategy for refractory RLS.

Click here for more coverage of SLEEP 2026.

REFERENCES
1. Silber MH, Berkowski JA, Buchfuhrer MJ, et al. An Updated Algorithm for the Management of Restless Legs Syndrome. Mayo Clin Proc. Published online May 26, 2026. doi:10.1016/j.mayocp.2026.05.010
2. Silber MH. Conversations and Controversies in RLS Management: Insights from the 2026 RLS Foundation Algorithm. Presented at: 2026 SLEEP Annual Meeting; June 14-17; Baltimore, Maryland.