Is ropinirole (a dopamine agonist) suitable for a 91-year-old patient?

From the Guidelines

Ropinirole should be avoided in a 91-year-old patient due to the increased risk of adverse effects, particularly augmentation, and the availability of alternative treatments with more favorable risk-benefit profiles, as suggested by the American Academy of Sleep Medicine 1. When considering the treatment of Restless Legs Syndrome (RLS) in elderly patients, it is essential to weigh the potential benefits against the risks of medication side effects.

• The American Academy of Sleep Medicine suggests against the standard use of ropinirole for RLS, citing moderate certainty of evidence 1.
• This recommendation is based on the potential for adverse effects, including augmentation, which can worsen symptoms over time.
• Alternative treatments, such as ferrous sulfate, dipyridamole, and extended-release oxycodone, may be considered, depending on the patient's individual needs and medical history.
• A comprehensive medication review is crucial to identify potential drug interactions and minimize the risk of adverse effects.
• Regular monitoring of side effects and efficacy is essential, with dose adjustments made slowly and carefully to ensure the best possible outcome for the patient.
• The patient's overall health status, including cognitive function, mobility, and presence of comorbidities, should be taken into account when making treatment decisions, as highlighted in the clinician's guide to geriatric assessment 1.

From the FDA Drug Label

Dose adjustment is not necessary in elderly (65 years and older) patients, as the dose of ropinirole is individually titrated to clinical therapeutic response and tolerability. In flexible-dose clinical trials of extended-release ropinirole for Parkinson’s disease, 387 patients were 65 years and older and 107 patients were 75 years and older. Among patients receiving extended-release ropinirole, hallucination was more common in elderly patients (10%) compared with non-elderly patients (2%) In these trials, the incidence of overall adverse reactions increased with increasing age for both patients receiving extended-release ropinirole and placebo.

Ropinirole use in a 91-year-old patient:

• No dose adjustment is necessary based solely on age, as the dose is individually titrated.
• However, caution is advised due to the increased incidence of adverse reactions, including hallucinations, with increasing age.
• Close monitoring of the patient's response to the medication and adjustment of the dose as needed is recommended 2.

From the Research

Ropinirole for a 91-year-old

• The use of ropinirole in elderly patients, particularly those over 65 years, has been studied in the context of Parkinson's disease treatment 3.
• A study published in 2019 found that the plasma concentration of ropinirole was not significantly affected by age, suggesting that dose adjustments may not be necessary based on age alone 3.
• However, the study also noted that there is high intersubject variability in plasma concentrations at the same dosage, which may require individualized treatment monitoring 3.
• Ropinirole has been compared to other dopamine agonists, such as pramipexole and rotigotine, in terms of efficacy and safety in treating restless legs syndrome and Parkinson's disease 4, 5, 6.
• These studies suggest that ropinirole is generally well-tolerated and effective in elderly patients, but that careful consideration of the benefit-risk ratio is necessary due to potential adverse effects 4, 5, 6.
• It is worth noting that there is limited information available on the use of ropinirole in patients over 90 years old, and that anticoagulation therapy in elderly patients should be carefully managed due to the risk of bleeding and thromboembolism 7.