What is the recommended titration schedule for ropinirole (Requip)?

Ropinirole Titration Schedule

For Restless Legs Syndrome (RLS), ropinirole should be started at 0.25 mg once daily 1-3 hours before bedtime, with weekly titration up to a maximum of 4 mg daily as needed for symptom control. 1, 2

Titration Schedule for Restless Legs Syndrome

• Initial dose: 0.25 mg once daily 1-3 hours before bedtime for 2 days 1
• Days 3-7: Increase to 0.5 mg once daily 1
• Week 2: Increase to 1 mg once daily 1
• Week 3: Increase to 1.5 mg once daily 1
• Week 4: Increase to 2 mg once daily 1
• Week 5: Increase to 2.5 mg once daily 1
• Week 6: Increase to 3 mg once daily 1
• Week 7: Increase to 4 mg once daily (maximum recommended dose) 1, 2

Titration Schedule for Parkinson's Disease

• Week 1: 0.25 mg three times daily (total daily dose: 0.75 mg) 1
• Week 2: 0.5 mg three times daily (total daily dose: 1.5 mg) 1
• Week 3: 0.75 mg three times daily (total daily dose: 2.25 mg) 1
• Week 4: 1 mg three times daily (total daily dose: 3 mg) 1
• After Week 4: May increase by 1.5 mg/day weekly up to 9 mg/day 1
• Further increases: May increase by up to 3 mg/day weekly up to maximum 24 mg/day (8 mg three times daily) 1, 3

Special Considerations

Renal Impairment

• Moderate renal impairment: No dose adjustment necessary 1
• End-stage renal disease on hemodialysis:
  • For RLS: Start with 0.25 mg once daily; maximum 3 mg/day 1
  • For Parkinson's: Start with 0.25 mg three times daily; maximum 18 mg/day 1

Dosing Pearls

• Titration should be based on individual therapeutic response and tolerability 1, 2
• For RLS, doses greater than 4 mg daily have not been established as safe or effective 1
• Taking ropinirole with food may reduce nausea, a common side effect during titration 1
• If a significant interruption in therapy occurs, retitration is recommended 1

Prolonged Release Formulation

• Available as a once-daily formulation (ropinirole PR) 4
• Allows for more stable plasma levels and potentially better tolerability 4, 5
• Switching from immediate release to prolonged release can be done overnight at the nearest equivalent total daily dose 4

Common Side Effects to Monitor During Titration

• Nausea, dizziness, somnolence, and orthostatic hypotension are common during dose escalation 5
• Side effects can often be minimized by slow titration as outlined above 1, 2

Discontinuation

• For RLS: Gradual reduction of the daily dose is recommended to prevent withdrawal symptoms 1
• For Parkinson's disease: Should be discontinued gradually over a 7-day period 1

Clinical Pearls

• 75% of Parkinson's patients who experience therapeutic response do so at doses ≤7.5 mg/day 3
• Continued dose titration may provide additional benefit in Parkinson's disease 3
• Ropinirole has a half-life of approximately 6 hours, which supports the three times daily dosing for immediate release formulation 6
• The bioavailability of ropinirole is approximately 50% 6

Remember that careful titration according to this schedule helps minimize adverse effects while achieving optimal therapeutic benefit 2, 1.