Is twice daily use of ropinirole (Requip) necessary for Restless Legs Syndrome (RLS)?

From the Guidelines

Ropinirole does not necessarily require twice daily dosing for restless legs syndrome (RLS), as the American Academy of Sleep Medicine suggests against its standard use, with a conditional recommendation and moderate certainty of evidence 1. For most patients with RLS, a single evening dose of ropinirole is sufficient and preferred, typically taken 1-3 hours before bedtime. The standard dosing ranges from 0.25 mg to 4 mg once daily, with most patients finding relief at 2 mg or less. This evening dosing schedule aligns with the circadian pattern of RLS symptoms, which typically worsen in the evening and night. Some key points to consider when treating RLS include:

• The AASM suggests the use of ferrous sulfate over no ferrous sulfate in patients with appropriate iron status 1.
• The AASM suggests against the standard use of levodopa, pramipexole, transdermal rotigotine, and ropinirole, due to the risk of adverse effects with long-term use, particularly augmentation 1.
• Twice-daily dosing might be considered for patients who experience breakthrough symptoms during the day or early evening, but this is less common for typical RLS.
• The medication works by stimulating dopamine receptors in the brain, addressing the dopamine dysfunction thought to underlie RLS symptoms.
• If once-daily dosing proves insufficient, before moving to twice-daily dosing, consider whether the timing of the dose is optimal or if a longer-acting formulation like ropinirole extended-release might be more appropriate.
• Always start with the lowest effective dose to minimize side effects like nausea, dizziness, and the potential for augmentation (worsening of symptoms) with long-term use 1.

From the FDA Drug Label

2.3 Dosing for Restless Legs Syndrome The recommended adult starting dose for RLS is 0.25 mg once daily 1 to 3 hours before bedtime. For RLS, the safety and effectiveness of doses greater than 4 mg once daily have not been established.

The use of ropinirole twice daily is not necessary for RLS, as the recommended dosing is once daily. The dose can be titrated up to a maximum of 4 mg once daily as needed to achieve efficacy 2.

From the Research

Ropinirole Dosage for RLS

• The optimal dosage of ropinirole for Restless Legs Syndrome (RLS) is not explicitly stated as twice daily in the provided studies 3, 4, 5, 6.
• However, the studies suggest that ropinirole is effective in reducing symptoms of RLS, with dosages ranging from 0.25-4.0 mg/day 6 and 0.5-12.0 mg/day 5.
• The frequency of administration is not specified, but it is implied that ropinirole can be taken once daily, 1 to 3 hours before bedtime 6.

Efficacy of Ropinirole for RLS

• Ropinirole has been shown to be effective in reducing symptoms of RLS in several studies 3, 4, 5, 6.
• The studies demonstrate significant improvements in International Restless Legs Scale (IRLS) scores, Clinical Global Impression-Improvement (CGI-I) scale scores, and sleep quality parameters 6.
• Ropinirole is also well-tolerated, with minimal side effects and no reports of disease augmentation 6.

Comparison with Other Treatments

• Ropinirole has been compared to other treatments for RLS, including gabapentin 4 and placebo 6.
• The studies suggest that ropinirole is similarly effective to gabapentin in reducing symptoms of RLS 4 and more effective than placebo 6.
• Other treatment options for RLS are also available, including alternative pharmacological agents such as clonidine, adenosinergic agents, and anticonvulsants 7.