Can ropinirole (Requip) cause hallucinations?

Ropinirole and Hallucinations

Yes, ropinirole (Requip) can definitely cause hallucinations as a significant adverse effect, particularly in elderly patients and those with advanced Parkinson's disease.

Mechanism and Risk

Ropinirole is a non-ergoline dopamine agonist that acts primarily on D2-type dopamine receptors. The FDA drug label specifically warns about hallucinations as a potential adverse effect:

• The FDA label explicitly states that patients may experience hallucinations (unreal visions, sounds, or sensations) and other psychotic-like behaviors while taking ropinirole 1
• Patients at highest risk include:
  • Elderly individuals
  • Those with Parkinson's disease (versus RLS patients)
  • Patients taking higher doses of ropinirole
  • Those taking ropinirole with L-dopa or other medications that increase dopaminergic tone 1

Evidence from Clinical Experience

Multiple clinical studies have documented hallucinations as a significant adverse effect:

• In early therapy trials, hallucinations were among the adverse experiences more common with ropinirole compared to placebo 2
• In adjunct therapy for Parkinson's disease, hallucinations were one of the four most common adverse effects 2
• Unlike other side effects that tend to decrease over time (such as nausea), the incidence of hallucinations may not diminish with continued treatment 2

Incidence and Comparison to Other Medications

• A meta-analysis comparing ropinirole with pramipexole found that both medications can cause hallucinations, though pramipexole showed a higher risk of hallucinations compared to placebo (RR 5.2 [95% CI 1.97-13.72]) than ropinirole (RR 2.75 [95% CI 0.55-13.73]) 3

• An exploratory retrospective study found that patients being treated with ropinirole for either Parkinson's disease or Restless Legs Syndrome may develop psychotic features requiring therapeutic intervention 4

• The risk appears to be significantly increased when ropinirole is used as part of a dual therapy approach with other dopamine agonists (p = 0.003) 4

Management of Hallucinations

If hallucinations occur while taking ropinirole:

1. Patients should report hallucinations or psychotic-like behavior to their healthcare provider promptly 1

2. Management options include:

   • Dose reduction of ropinirole
   • Addition of an antipsychotic medication
   • Discontinuation of ropinirole if symptoms are severe 4

3. For patients with RLS, current guidelines from the American Academy of Sleep Medicine (2025) suggest against the standard use of ropinirole, noting that it "may be used to treat RLS in patients who place a higher value on the reduction of restless legs symptoms with short-term use and a lower value on adverse effects with long-term use" 5

Important Considerations

• Hallucinations may be more likely to occur in patients with altered mental status or cognitive impairment 6
• The risk of hallucinations appears to increase with age, making elderly patients particularly vulnerable 1
• Patients and caregivers should be educated about this potential side effect before starting treatment

Monitoring for early signs of hallucinations is essential, especially when initiating therapy or increasing the dose of ropinirole.