How quickly does Requip (ropinirole) start working for restless leg syndrome?

Onset of Action for Ropinirole (Requip) in Restless Legs Syndrome

Ropinirole begins working within the first week of treatment, with statistically significant improvements in RLS symptoms observed as early as week 1 in clinical trials. 1, 2

Timeline of Symptom Improvement

Initial response occurs rapidly:

• Patients experience measurable improvement in International Restless Legs Scale (IRLS) scores within the first week of starting ropinirole 2
• Some case series report beneficial effects after the very first dose, though this represents anecdotal rather than controlled trial evidence 3
• The medication is taken 1-3 hours before bedtime, allowing it to reach peak effect when symptoms typically worsen 4, 1

Maximal therapeutic benefit develops over several weeks:

• Clinical trials measured primary outcomes at 12 weeks, showing continued improvement from baseline with mean IRLS score reductions of 11-13.5 points (on a 40-point scale) compared to 8-9.8 points with placebo 1
• The difference between ropinirole and placebo was 2.5-3.7 points at week 12, which was statistically significant but clinically modest 1, 5

Dosing Strategy and Titration

Start with 0.25 mg taken 1-3 hours before bedtime: 4, 1

• Increase to 0.5 mg after 2-3 days if needed 4
• Advance to 1 mg after 7 days 4
• Continue weekly 0.5 mg increments up to a maximum of 4 mg at week 7 if symptoms persist 4
• Mean effective dose in clinical trials was approximately 2 mg/day 1

Critical Caveats About Long-Term Use

Current guidelines recommend AGAINST standard use of ropinirole due to augmentation risk: 4, 6

• The American Academy of Sleep Medicine (2025) suggests against standard use of ropinirole (conditional recommendation, moderate certainty of evidence) 4
• Augmentation—characterized by earlier onset of symptoms during the day, increased intensity, and spread to other body parts—is a significant concern with long-term dopaminergic therapy 4, 5
• Ropinirole may only be appropriate for patients who prioritize short-term symptom relief over long-term adverse effects 4

Alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) are now first-line therapy: 4, 6

• These agents have lower augmentation risk and are strongly recommended by the American Academy of Sleep Medicine (2025) 4, 6
• If ropinirole is used, it should be with explicit understanding of augmentation risk and a plan for monitoring and switching if needed 6, 7

Common Side Effects During Initial Treatment

Expect dopaminergic adverse effects: 4, 1, 5

• Nausea and vomiting (most common) 5, 8
• Orthostatic hypotension and dizziness 4, 5
• Somnolence and sudden sleep attacks 5
• Headache 4
• In older patients, particular attention to orthostasis and drug interactions is essential 4

Practical Clinical Approach

Before starting ropinirole, check iron status: 6, 9

• Measure morning fasting ferritin and transferrin saturation 6
• If ferritin ≤75 ng/mL or transferrin saturation <20%, iron supplementation should be the initial intervention 6

If dopaminergic therapy is chosen despite guideline recommendations:

• Begin with 0.25 mg 1-3 hours before bedtime 4, 1
• Assess response within the first week 2
• Titrate slowly based on symptom control and tolerability 4
• Monitor closely for augmentation signs: symptoms starting earlier in the day, increased intensity, or spread to arms/trunk 4, 5
• Have a transition plan to alpha-2-delta ligands if augmentation develops 6, 7