Ropinirole Dosing for Restless Legs Syndrome
For restless legs syndrome, start ropinirole at 0.25 mg once daily taken 1-3 hours before bedtime, and titrate up to a maximum single nighttime dose of 4 mg daily based on symptom response. 1
FDA-Approved Dosing Schedule
The FDA label provides a specific titration protocol for RLS 1:
- 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 dose)
All doses should be taken 1-3 hours before bedtime as a single nighttime dose. 1 Doses greater than 4 mg daily have not been established as safe or effective for RLS. 1
Critical Guideline Considerations Before Prescribing
The American Academy of Sleep Medicine now suggests against the standard use of ropinirole for RLS due to augmentation risk (conditional recommendation, moderate certainty of evidence). 2 Augmentation is characterized by earlier onset of symptoms during the day, increased symptom intensity, and spread of symptoms to other body parts. 2
Preferred First-Line Treatment
Alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) are now strongly recommended as first-line therapy over dopamine agonists like ropinirole due to lower augmentation risk. 2, 3
When Ropinirole May Be Considered
Ropinirole may only be appropriate for patients who 2:
- Prioritize short-term symptom relief over long-term adverse effects
- Are explicitly informed of augmentation risk
- Have a monitoring and switching plan if augmentation develops
Special Population Dosing
End-stage renal disease on hemodialysis: Start at 0.25 mg once daily with a maximum of 3 mg/day (not 4 mg). 1 No supplemental doses after dialysis are required. 1
Moderate renal impairment (CrCl 30-50 mL/min): No dose adjustment necessary. 1
Key Monitoring and Safety Points
Watch for these side effects, particularly in older patients 2:
- Orthostatic hypotension and dizziness
- Headache
- Nausea
Monitor closely for augmentation signs, which require dose reduction or switching to alpha-2-delta ligands. 2, 4
Discontinuation Protocol
When stopping ropinirole, gradual reduction is recommended rather than abrupt cessation. 1 Consider transitioning to gabapentin or pregabalin if augmentation develops. 4