What is the starting dose of Requip (ropinirole) for a patient with Parkinson's disease or restless legs syndrome?

Requip (Ropinirole) Starting Dose

Parkinson's Disease

For Parkinson's disease, start ropinirole at 0.25 mg three times daily, then titrate weekly based on response and tolerability. 1

Initial Dosing 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

Subsequent Titration

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

Special Populations

• End-stage renal disease on hemodialysis: Start at 0.25 mg three times daily, with a maximum total daily dose of 18 mg/day 1
• Moderate renal impairment (CrCl 30-50 mL/min): No dose adjustment necessary 1

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Restless Legs Syndrome

For restless legs syndrome, the FDA-approved starting dose is 0.25 mg once daily, taken 1-3 hours before bedtime—however, current guidelines strongly recommend against using ropinirole as first-line therapy due to high augmentation risk. 1, 2

Critical Guideline Update

• The American Academy of Sleep Medicine (2026) recommends against standard use of ropinirole for RLS due to high risk of augmentation, where symptoms worsen, appear earlier in the day, and spread to arms or trunk 2
• Alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) are now strongly recommended as first-line therapy with moderate certainty of evidence 2

FDA-Approved Titration Schedule (If Used Despite Guidelines)

• Days 1-2: 0.25 mg once daily 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

Special Populations for RLS

• End-stage renal disease on hemodialysis: Start at 0.25 mg once daily, with a maximum of 3 mg/day 1
• Patients with end-stage renal disease on hemodialysis: Gabapentin is preferred over ropinirole despite very low certainty of evidence, due to lower augmentation risk 2

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Important Clinical Considerations

Pre-Treatment Evaluation for RLS

• Check morning fasting ferritin and transferrin saturation before initiating any pharmacological treatment 2
• Supplement with iron if ferritin ≤75 ng/mL or transferrin saturation <20% 2

Common Pitfalls

• Augmentation is a substantial risk with ropinirole in RLS, occurring in a significant proportion of patients and representing long-term harm that outweighs short-term benefits 2, 3
• When discontinuing ropinirole, taper gradually over 7 days to avoid withdrawal symptoms 1
• For Parkinson's disease, reduce from three times daily to twice daily for 4 days, then once daily for 3 days before complete withdrawal 1
• Consider transitioning to gabapentin or pregabalin during the taper for RLS patients 2

Administration

• Ropinirole can be taken with or without food 1
• If significant therapy interruption occurs, retitration may be warranted 1