What is the recommended dosing for Requip (ropinirole) in a patient with Parkinson's disease or restless legs syndrome, considering potential renal impairment?

Ropinirole Dosing

Ropinirole is no longer recommended as standard treatment for restless legs syndrome due to high risk of augmentation, and should be avoided in favor of alpha-2-delta ligands (gabapentin, pregabalin) as first-line therapy. 1

Current Treatment Paradigm for Restless Legs Syndrome

The American Academy of Sleep Medicine explicitly recommends against the standard use of ropinirole (conditional recommendation, moderate certainty of evidence) because dopamine agonists cause augmentation—a paradoxical worsening of symptoms characterized by earlier onset during the day, increased intensity, and spread to other body parts. 1, 2, 3

First-Line Treatment Instead of Ropinirole

• Gabapentin, gabapentin enacarbil, or pregabalin are strongly recommended as first-line therapy (strong recommendation, moderate certainty of evidence). 1
• Before any pharmacological treatment, check morning fasting ferritin and transferrin saturation, and supplement with iron if ferritin ≤75 ng/mL or transferrin saturation <20%. 1

FDA-Approved Ropinirole Dosing (For Historical Reference Only)

If ropinirole must be used despite guideline recommendations against it, the FDA-approved dosing is:

For Restless Legs Syndrome:

• Starting dose: 0.25 mg once daily, taken 1-3 hours before bedtime 4
• Titration schedule: 4
  • Days 1-2: 0.25 mg
  • Days 3-7: 0.5 mg
  • Week 2: 1 mg
  • Week 3: 1.5 mg
  • Week 4: 2 mg
  • Week 5: 2.5 mg
  • Week 6: 3 mg
  • Week 7: 4 mg (maximum dose)
• Maximum dose: 4 mg once daily 4

For Parkinson's Disease:

• Starting dose: 0.25 mg three times daily 4
• Titration: Increase weekly up to 1 mg three times daily by Week 4, then by 1.5 mg/day weekly up to 9 mg/day, then by 3 mg/day weekly up to maximum 24 mg/day (8 mg three times daily) 4

Renal Impairment Dosing

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

• No dose adjustment necessary 4

End-Stage Renal Disease on Hemodialysis:

• For RLS: Start 0.25 mg once daily, maximum 3 mg/day 4
• For Parkinson's: Start 0.25 mg three times daily, maximum 18 mg/day 4
• No supplemental doses after dialysis required 4

Critical caveat: Even in dialysis patients with RLS, gabapentin (100 mg post-dialysis or at bedtime, maximum 200-300 mg daily) is preferred over ropinirole despite very low certainty of evidence, because it avoids augmentation risk. 2, 3

Why Ropinirole Should Be Avoided

• Augmentation occurs in a substantial proportion of patients, causing symptoms to worsen, appear earlier in the day, and spread to arms or trunk. 5, 1
• The 2026 American Academy of Sleep Medicine guidelines represent a paradigm shift away from dopamine agonists after recognizing their long-term harms outweigh short-term benefits. 1
• Older studies from 1999-2006 showed short-term efficacy 6, 7, 8, but long-term data revealed unacceptable augmentation rates, leading to the current recommendations against their use. 1

Discontinuation Protocol

If a patient is currently on ropinirole and needs to discontinue:

• Gradual taper over 7 days is recommended to avoid withdrawal symptoms 4
• Consider transitioning to gabapentin or pregabalin during the taper 1
• Extended-release oxycodone may be needed for refractory augmentation cases 1