What is the recommended dosing regimen for Ropinirole (a dopamine agonist)?

Ropinirole Dosing

For Parkinson's disease, start ropinirole at 0.25 mg three times daily and titrate weekly up to 24 mg/day total; for restless legs syndrome, start at 0.25 mg once daily 1-3 hours before bedtime and titrate up to a maximum of 4 mg/day. 1

Parkinson's Disease Dosing

Initial Titration Schedule

• Week 1: 0.25 mg three times daily (total 0.75 mg/day) 1
• Week 2: 0.5 mg three times daily (total 1.5 mg/day) 1
• Week 3: 0.75 mg three times daily (total 2.25 mg/day) 1
• Week 4: 1 mg three times daily (total 3 mg/day) 1

Continued Dose Escalation

• After Week 4, increase by 1.5 mg/day weekly up to 9 mg/day 1
• Beyond 9 mg/day, increase by up to 3 mg/day weekly 1
• Maximum dose: 24 mg/day (8 mg three times daily) 1
• Doses greater than 24 mg/day have not been tested in clinical trials 1

Clinical Response Expectations

• 75% of patients who experience therapeutic response do so at ≤7.5 mg/day 2
• However, continued dose titration beyond initial response provides additional benefit in most patients 2
• Mean doses in long-term studies continued to increase: 10.4 mg/day at 3 years and 14.9 mg/day at 5 years 2
• Patients with dose increases >4 titration levels showed greater improvements (17.4%) compared to smaller increases (10.8%) 2

Discontinuation Protocol

• Taper gradually over 7 days 1
• Days 1-4: Reduce from three times daily to twice daily 1
• Days 5-7: Reduce to once daily before complete withdrawal 1

Restless Legs Syndrome Dosing

Titration Schedule

• Days 1-2: 0.25 mg once daily, 1-3 hours before bedtime 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 (maximum dose) 1

Important RLS Considerations

• The American Academy of Sleep Medicine suggests against standard use of ropinirole for RLS due to augmentation risk (conditional recommendation, moderate certainty) 3
• Reserve ropinirole only for patients who prioritize short-term symptom reduction over long-term adverse effect concerns 3
• Doses greater than 4 mg once daily have not been established as safe or effective for RLS 1
• When discontinuing, gradually reduce the daily dose 1

Renal Impairment Adjustments

Moderate Renal Impairment (CrCl 30-50 mL/min)

• No dose adjustment necessary 1

End-Stage Renal Disease on Hemodialysis

For Parkinson's Disease:

• Initial dose: 0.25 mg three times daily 1
• Maximum total daily dose: 18 mg/day 1
• Supplemental doses after dialysis are not required 1

For Restless Legs Syndrome:

• Initial dose: 0.25 mg once daily 1
• Maximum total daily dose: 3 mg/day 1
• Supplemental doses after dialysis are not required 1

Severe Renal Impairment Without Dialysis

• Use has not been studied; avoid or use with extreme caution 1

Administration Guidelines

• Can be taken with or without food 1
• If significant interruption in therapy occurs, retitration may be warranted 1
• Titrate based on individual therapeutic response and tolerability 1

Critical Monitoring Parameters

Augmentation in RLS

• Monitor for earlier symptom onset during the day 3
• Watch for increased symptom intensity 3
• Assess for spread of symptoms to previously unaffected body parts 3
• If augmentation occurs, switch to alpha-2-delta ligands (gabapentin, pregabalin) rather than increasing ropinirole dose 4

Cardiovascular Monitoring

• Monitor for orthostatic hypotension, especially when initiating therapy or increasing dose 3
• Older patients are at particular risk for orthostasis 3

Neuropsychiatric Monitoring

• Monitor for hallucinations, particularly in older patients 3
• Screen for compulsive behaviors including gambling, increased sexual urges, uncontrollable shopping, and compulsive eating 3
• Assess for somnolence and sudden sleep onset 3

Dose Equivalency Across Dopamine Agonists

• 15 mg ropinirole ≈ 30 mg bromocriptine ≈ 4.5 mg pramipexole ≈ 3 mg pergolide 5