Highest Recommended Dose of Ropinirole
The maximum recommended dose of ropinirole is 24 mg/day (8 mg three times daily) for Parkinson's disease and 4 mg/day (single dose) for restless legs syndrome (RLS). 1
Dosing by Indication
Parkinson's Disease
- Maximum dose: 24 mg/day divided as 8 mg three times daily 1
- Initial dose starts at 0.25 mg three times daily (0.75 mg/day total) 1
- Titrate weekly: increase to 0.5 mg TID (Week 2), 0.75 mg TID (Week 3), and 1 mg TID (Week 4) 1
- After Week 4, increase by 1.5 mg/day weekly up to 9 mg/day, then by 3 mg/day weekly up to the maximum of 24 mg/day 1
- Important caveat: Doses greater than 24 mg/day have not been tested in clinical trials 1
- Clinical data suggest that while 75% of patients respond at ≤7.5 mg/day, continued dose titration benefits most patients, with some requiring the full 24 mg/day maximum 2
Restless Legs Syndrome
- Maximum dose: 4 mg/day as a single dose taken 1-3 hours before bedtime 1
- Initial dose is 0.25 mg once daily 1
- Titration schedule: 0.25 mg (Days 1-2) → 0.5 mg (Days 3-7) → 1 mg (Week 2) → 1.5 mg (Week 3) → 2 mg (Week 4) → 2.5 mg (Week 5) → 3 mg (Week 6) → 4 mg (Week 7) 1
- The safety and effectiveness of doses greater than 4 mg once daily have not been established for RLS 1
- Mean effective dose in clinical trials was approximately 1.9-2.8 mg/day 3, 4
Critical Guideline Context: Ropinirole Is No Longer Recommended
The American Academy of Sleep Medicine now suggests AGAINST the standard use of ropinirole for RLS (conditional recommendation, moderate certainty of evidence) due to the risk of augmentation—a paradoxical worsening of symptoms with long-term use. 5
- Alpha-2-delta ligands (gabapentin, gabapentin enacarbil, pregabalin) are now strongly recommended as first-line therapy instead 5
- Dopamine agonists like ropinirole may only be considered for short-term treatment in patients who prioritize immediate symptom relief over long-term adverse effects 5
- This represents a major shift from older guidelines (2009) that recommended ropinirole as first-line therapy 6
Special Population Dosing
End-Stage Renal Disease (Hemodialysis)
- Parkinson's disease: Maximum 18 mg/day (lower than standard 24 mg/day) 1
- RLS: Maximum 3 mg/day (lower than standard 4 mg/day) 1
- Initial dose remains 0.25 mg for both indications 1
- Supplemental doses after dialysis are not required 1
Moderate Renal Impairment
- No dose adjustment necessary for creatinine clearance 30-50 mL/min 1