How do you manage moderately severe RLS in a patient with advanced CKD (eGFR 15–30) who has developed dopaminergic augmentation on a dopamine agonist, given that standard gabapentinoid replacement agents carry significant accumulation risk at this level of renal impairment?

This is a challenging picture. I suggest slow tapering of the dopamine agonist while proceeding to the next therapy. I propose the following steps.

1. Check ferritin/TSAT → give iron if low, IV iron may be needed.
2. Start low-dose gabapentin or pregabalin (renal dosing). Titrate cautiously.
3. Severe persistent RLS may benefit from low-dose methadone.
4. Reassess weekly during transition.
5. Below, I am copying the AASM recommendation published in JCSM in 2025:
   • Special adult populations with RLS:
     • 21. In ad...