Ropinirole Dosing for Parkinson's Disease and Restless Legs Syndrome
For Parkinson's Disease, ropinirole should be started at 0.25 mg three times daily and titrated weekly up to a maximum of 24 mg/day, while for Restless Legs Syndrome (RLS), the recommended starting dose is 0.25 mg once daily 1-3 hours before bedtime with a maximum dose of 4 mg/day. 1
Dosing for Parkinson's Disease
Initial Dosing and Titration
- Starting dose: 0.25 mg three times daily 1
- Titration schedule:
- Week 1: 0.25 mg three times daily (0.75 mg/day)
- Week 2: 0.5 mg three times daily (1.5 mg/day)
- Week 3: 0.75 mg three times daily (2.25 mg/day)
- Week 4: 1 mg three times daily (3 mg/day) 1
- After Week 4: Increase by 1.5 mg/day weekly up to 9 mg/day, then by up to 3 mg/day weekly
- Maximum recommended dose: 24 mg/day (8 mg three times daily) 1
Clinical Considerations
- Most patients who experience therapeutic response do so at ≤7.5 mg/day, but continued dose titration may provide additional benefit 2
- In long-term management, mean doses may increase over time (10.4-14.9 mg/day at 3-5 years) 2
- High-dose ropinirole (20-36 mg/day) has shown significant clinical benefit in patients with motor fluctuations 3
Discontinuation
- Ropinirole should be discontinued gradually over a 7-day period:
- Reduce from three times daily to twice daily for 4 days
- Then reduce to once daily for 3 days before complete withdrawal 1
Dosing for Restless Legs Syndrome (RLS)
Initial Dosing and Titration
- Starting dose: 0.25 mg once daily, 1-3 hours before bedtime 1, 4
- Titration schedule:
- Days 1-2: 0.25 mg once daily
- Days 3-7: 0.5 mg once daily
- Week 2: 1 mg once daily
- Week 3: 1.5 mg once daily
- Week 4: 2 mg once daily
- Week 5: 2.5 mg once daily
- Week 6: 3 mg once daily
- Week 7: 4 mg once daily 1
- Maximum recommended dose: 4 mg once daily 1, 5
Clinical Considerations
- Efficacy may be observed after the first administration 6
- Significantly improves RLS symptoms compared to placebo, with benefits apparent by week 1 7
- Improves overall sleep quality and health-related quality of life 7
- The dose required for RLS is much smaller than what is necessary for Parkinson's disease 8
Discontinuation
- Gradual reduction of the daily dose is recommended when discontinuing ropinirole for RLS 1
Special Populations: Renal Impairment
Parkinson's Disease
- Moderate renal impairment: No dose adjustment necessary
- End-stage renal disease on hemodialysis:
- Starting dose: 0.25 mg three times daily
- Maximum dose: 18 mg/day
- Supplemental doses after dialysis not required 1
Restless Legs Syndrome
- Moderate renal impairment: No dose adjustment necessary
- End-stage renal disease on hemodialysis:
- Starting dose: 0.25 mg once daily
- Maximum dose: 3 mg/day
- Supplemental doses after dialysis not required 1
Administration Considerations
- Can be taken with or without food 1
- If therapy is significantly interrupted, retitration may be warranted 1
- Common side effects include nausea, orthostatic hypotension, sleepiness, headache, and compulsive behaviors 4
- In older patients, particular consideration should be given to drug interactions and the risk of orthostasis 4
Important Cautions
- Dopamine agonists like ropinirole should be used for short-term management only due to the risk of augmentation 5
- Augmentation is characterized by worsening and earlier onset of symptoms in previously controlled patients 4
- Alpha-2-delta ligands (pregabalin or gabapentin) are now recommended as first-line treatments for RLS due to their favorable long-term safety profile 5
- Regular monitoring for medication side effects is essential, particularly for augmentation 5