Management of Ropinirole Overdose
The management of ropinirole overdose requires general supportive measures with close monitoring of vital signs, as there is no specific antidote for ropinirole toxicity. 1
Clinical Presentation of Ropinirole Overdose
Symptoms of ropinirole overdose are related to its dopaminergic activity and may include:
Common symptoms:
- Nausea and vomiting
- Dizziness
- Somnolence
- Confusion
- Hyperhidrosis
Severe manifestations:
- Visual hallucinations
- Dyskinesia
- Orthostatic hypotension
- Syncope
- Agitation
- Chorea
- Palpitations
Management Algorithm
1. Initial Assessment and Stabilization
- Assess and secure airway, breathing, and circulation
- Obtain vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation)
- Check blood glucose levels
- Perform neurological assessment
- Obtain ECG to assess for cardiac effects
2. Supportive Care
- Maintain vital signs with supportive measures
- Provide IV fluids for hypotension (if present)
- Position patient to prevent aspiration if vomiting occurs
- Administer antiemetics for severe nausea/vomiting
3. Decontamination
- Consider activated charcoal (1 g/kg) if presentation is within 1 hour of ingestion and airway is protected
- Do not induce emesis
4. Specific Management for Severe Symptoms
- For severe agitation or hallucinations: Consider low-dose benzodiazepines
- For severe hypotension: IV fluids and positioning; vasopressors if refractory
- For dyskinesia: Supportive care and monitoring
5. Monitoring
- Continuous cardiac monitoring
- Frequent vital sign checks
- Neurological assessments
- Monitor for at least 6-12 hours after ingestion, longer for severe cases
Toxic Levels and Prognosis
The therapeutic plasma level of ropinirole is 0.4-6 ng/mL 2. A case report documented a fatal intoxication with a peripheral blood concentration of 64 ng/mL in combination with alcohol 2. This represents the only documented fatal case in the literature and suggests that levels significantly above therapeutic range can be potentially lethal, particularly when combined with other central nervous system depressants.
Special Considerations
Elderly Patients
Elderly patients may be more sensitive to the effects of ropinirole overdose, particularly orthostatic hypotension and confusion. More cautious management with lower thresholds for intensive monitoring is warranted.
Patients with Psychiatric History
Patients with pre-existing psychiatric conditions may experience more severe hallucinations or psychosis with ropinirole overdose 3. These patients may require psychiatric consultation and more aggressive management of psychiatric symptoms.
Concomitant Medications
Be aware of potential drug interactions, particularly:
- Other dopaminergic medications (may potentiate effects)
- CNS depressants (may worsen respiratory depression)
- Antipsychotics (may antagonize ropinirole effects but could worsen other symptoms)
Common Pitfalls to Avoid
Misdiagnosis: Symptoms of ropinirole overdose may mimic other conditions such as serotonin syndrome or neuroleptic malignant syndrome.
Premature discharge: Patients should be observed for an adequate period as symptoms may fluctuate or worsen over time.
Failure to recognize concomitant ingestions: Many overdoses involve multiple substances, which can complicate management.
Inappropriate use of naloxone: Unlike opioid overdoses, ropinirole overdose will not respond to naloxone administration 4.
Inadequate monitoring: Continuous cardiac and neurological monitoring is essential due to the risk of cardiovascular effects and altered mental status.
The largest reported non-fatal overdose in clinical trials was 435 mg taken over a 7-day period (62.1 mg/day) 1, suggesting that ropinirole has a relatively wide safety margin in overdose situations when appropriate supportive care is provided.