Ropinirole Treatment Regimen for Parkinson's Disease and Restless Legs Syndrome
Ropinirole is not recommended as a standard treatment for Restless Legs Syndrome (RLS) due to the risk of augmentation, and alpha-2-delta ligands are now preferred as first-line therapy. 1, 2
Dosing for Parkinson's Disease
- The recommended starting dose of ropinirole for Parkinson's disease is 0.25 mg 3 times daily 3
- Dose should be titrated with weekly increments according to the following schedule: 3
- Week 1: 0.25 mg 3 times daily (total: 0.75 mg/day)
- Week 2: 0.5 mg 3 times daily (total: 1.5 mg/day)
- Week 3: 0.75 mg 3 times daily (total: 2.25 mg/day)
- Week 4: 1 mg 3 times daily (total: 3 mg/day)
- After Week 4, the daily dose may be increased by 1.5 mg/day weekly up to 9 mg/day, then by up to 3 mg/day weekly to a maximum of 24 mg/day (8 mg 3 times daily) 3
- Ropinirole can be taken with or without food 3
Discontinuation in Parkinson's Disease
- Ropinirole should be discontinued gradually over a 7-day period 3
- Reduce frequency from 3 times daily to twice daily for 4 days, then to once daily for 3 days before complete withdrawal 3
Dosing for Restless Legs Syndrome (Not Recommended as First-Line)
- The American Academy of Sleep Medicine suggests against the standard use of ropinirole for RLS due to risk of augmentation 1, 2
- Alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) are strongly recommended as first-line therapy for RLS 1
If Ropinirole Is Used Despite Recommendations Against It:
- Starting dose: 0.25 mg once daily 1-3 hours before bedtime 3
- Titration schedule: 3
- 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 (maximum recommended dose)
- Gradual dose reduction is recommended when discontinuing 3
Renal Impairment Considerations
- No dose adjustment needed for moderate renal impairment (creatinine clearance 30-50 mL/min) 3
- For end-stage renal disease on hemodialysis: 3
- Parkinson's disease: Start with 0.25 mg 3 times daily, maximum 18 mg/day
- RLS: Start with 0.25 mg once daily, maximum 3 mg/day
- Supplemental doses after dialysis are not required
Monitoring and Management of Adverse Effects
- Common adverse effects include nausea, vomiting, drowsiness, sudden urge to sleep, syncope, hypotension, and hallucinations 4
- Monitor for augmentation, characterized by: 1, 2
- Earlier onset of symptoms during the day
- Increased symptom intensity
- Spread of symptoms to other body parts
- Management options for augmentation include taking medication doses earlier in the day or splitting doses 2
Important Cautions and Alternatives
- Ropinirole has a negative risk-benefit balance in RLS, which is considered a minor health disorder 4
- For RLS, the American Academy of Sleep Medicine strongly recommends alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) as first-line therapy 1
- Check iron status in all RLS patients and consider supplementation if ferritin ≤75 ng/mL or transferrin saturation <20% 1, 5
- For patients with end-stage renal disease and RLS, gabapentin is recommended as first-line treatment 5