What is the recommended dosing for ropinirole (Requip) in the treatment of Parkinson's disease and restless legs syndrome?

Ropinirole Dosing for Parkinson's Disease and Restless Legs Syndrome

For Parkinson's disease, the recommended ropinirole dosing starts at 0.25 mg three times daily, gradually titrating up to a maximum of 24 mg/day; for restless legs syndrome, dosing starts at 0.25 mg once daily 1-3 hours before bedtime, titrating up to a maximum of 4 mg/day. 1

Dosing for Parkinson's Disease

• Initial dose: 0.25 mg three times daily 1
• Titration schedule:
  • Week 1: 0.25 mg three times daily (0.75 mg/day) 1
  • Week 2: 0.5 mg three times daily (1.5 mg/day) 1
  • Week 3: 0.75 mg three times daily (2.25 mg/day) 1
  • 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 1
• Maximum recommended dose: 24 mg/day (8 mg three times daily) 1
• Discontinuation: Gradually over a 7-day period, reducing from three times daily to twice daily for 4 days, then once daily for 3 days 1

Dosing for Restless Legs Syndrome (RLS)

• Initial dose: 0.25 mg once daily 1-3 hours before bedtime 1
• Titration schedule:
  • Days 1-2: 0.25 mg once daily 1
  • Days 3-7: 0.5 mg once daily 1
  • Week 2: 1 mg once daily 1
  • Week 3: 1.5 mg once daily 1
  • Week 4: 2 mg once daily 1
  • Week 5: 2.5 mg once daily 1
  • Week 6: 3 mg once daily 1
  • Week 7: 4 mg once daily 1
• Maximum recommended dose: 4 mg once daily 1
• Discontinuation: Gradual reduction of the daily dose is recommended 1

Special Considerations

Renal Impairment

• Moderate renal impairment: No dose adjustment necessary 1
• End-stage renal disease on hemodialysis:
  • For Parkinson's disease: 0.25 mg three times daily initially, maximum 18 mg/day 1
  • For RLS: 0.25 mg once daily initially, maximum 3 mg/day 1
  • Supplemental doses after dialysis are not required 1

Efficacy and Side Effects

• Ropinirole significantly improves RLS symptoms compared to placebo, with benefits apparent by week 1 2, 3
• Most common adverse events include nausea and headache 2, 3
• The dosage needed for RLS is much smaller than for Parkinson's disease 4

Important Considerations for RLS Treatment

• Current guidelines from the American Academy of Sleep Medicine suggest against the standard use of dopamine agonists like ropinirole for RLS due to risk of augmentation with long-term use 5
• Alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) are now recommended as first-line therapy for RLS 5
• If considering ropinirole for RLS, be aware of the risk of augmentation - characterized by worsening and earlier onset of symptoms in patients initially controlled on medication 6
• Management options for augmentation include taking medication doses earlier in the day or splitting existing doses into early evening and bedtime doses 6

Administration

• Ropinirole can be taken with or without food 1
• If therapy is interrupted significantly, retitration may be necessary 1