What is the starting dose and titration rate for Requip (Ropinirole) in elderly adults?

Ropinirole (Requip) Dosing in Elderly Adults

For elderly adults with restless legs syndrome (RLS), start ropinirole at 0.25 mg orally 1-3 hours before bedtime, increase to 0.5 mg after 2-3 days, then to 1 mg after 7 days, with weekly 0.5 mg increments up to a maximum of 4 mg by week 7 if needed. 1

Starting Dose Considerations

• Begin with 0.25 mg orally taken 1-3 hours before bedtime for RLS in older patients 1
• This conservative starting dose accounts for age-related pharmacokinetic changes, as clearance is slower in patients older than 65 years compared to younger individuals 2
• The lower initial dose helps minimize common side effects including nausea, orthostatic hypotension, somnolence, hallucinations, and edema 3

Titration Schedule

The titration should follow a structured, gradual approach:

• Days 3-7: Increase to 0.5 mg if tolerated 1
• Week 1: Increase to 1 mg 1
• Weeks 2-7: Increase by 0.5 mg increments weekly as needed, up to maximum 4 mg 1

Critical Safety Considerations for Elderly Patients

Orthostatic hypotension risk is particularly important in older adults:

• Monitor blood pressure carefully during titration 1, 3
• Assess for dizziness and falls risk at each dose increase 3

Drug interactions require special attention:

• Ciprofloxacin (a CYP1A2 inhibitor) significantly increases ropinirole plasma concentrations and should be avoided or require dose reduction 2
• Women taking hormone replacement therapy have slower clearance and may require lower doses 2

Cognitive and psychiatric effects:

• Watch for hallucinations, confusion, and excessive somnolence, which are more common in elderly patients 3, 4
• Some patients experience sudden sleep onset without warning 4

Maximum Dosing

• For RLS in elderly adults, the maximum recommended dose is 4 mg daily 1
• This is substantially lower than the 24 mg maximum used in Parkinson's disease 5
• Most elderly patients with RLS respond at doses ≤1 mg, with 75% of responders achieving benefit at ≤7.5 mg in Parkinson's disease studies 5

Common Pitfalls to Avoid

• Do not titrate too rapidly: The elderly require longer intervals between dose increases to assess tolerability 1
• Do not ignore renal function: While mild-to-moderate renal impairment doesn't significantly affect pharmacokinetics, severe impairment may require dose adjustment 2
• Do not overlook medication reconciliation: Check for CYP1A2 inhibitors before initiating therapy 2
• Do not dismiss early side effects: Nausea and dizziness often improve with continued use but may require temporary dose reduction 3, 4

Monitoring During Titration

• Assess symptom control and side effects at each dose increase 1
• Monitor for orthostatic vital sign changes, particularly in the first weeks 3
• Evaluate for excessive daytime somnolence, which can impair driving and increase fall risk 4
• Consider dose reduction rather than discontinuation if side effects emerge, as many are dose-dependent 3