Can a mental‑health nurse practitioner prescribe ropinirole (Requip) for restless‑legs syndrome within their scope of practice?

Scope of Practice for Mental Health Nurse Practitioners Prescribing Ropinirole

Mental health nurse practitioners can legally prescribe ropinirole (Requip) for restless legs syndrome in most jurisdictions, as it falls within their prescriptive authority for medications affecting neurological and psychiatric conditions—however, current evidence strongly recommends AGAINST using ropinirole as standard treatment for RLS due to high augmentation risk. 1, 2, 3

Legal Scope vs. Evidence-Based Practice

Prescriptive Authority

• Mental health nurse practitioners typically have full prescriptive authority for medications that affect the central nervous system, including dopamine agonists like ropinirole 4
• Ropinirole is FDA-approved for RLS and does not require specialty certification to prescribe 5
• The legal ability to prescribe does not mean it is the appropriate first-line choice based on current guidelines 1, 2

Current Evidence-Based Recommendations

The American Academy of Sleep Medicine (2025) explicitly recommends AGAINST standard use of ropinirole for RLS due to augmentation risk (conditional recommendation, moderate certainty of evidence). 1, 2, 3

Why Ropinirole Is No Longer Recommended:

• Augmentation occurs in 7-10% of patients annually, manifesting as earlier symptom onset (afternoon instead of evening), increased intensity, and spread to arms/trunk 1, 2
• This represents a paradoxical worsening despite initial symptom control 1, 3
• The 2025 guidelines represent a major shift from 2009 recommendations that favored dopamine agonists 2

What Should Be Prescribed Instead

First-Line Treatment Algorithm:

Step 1: Assess Iron Status

• Check morning fasting ferritin and transferrin saturation after ≥24-hour iron-free interval 1
• Supplement if ferritin ≤75 ng/mL or transferrin saturation <20% 1

Step 2: Alpha-2-Delta Ligands (Strong Recommendation)

• Gabapentin: Start 300 mg three times daily; increase by 300 mg/day every 3-7 days; target 1800-2400 mg/day divided TID 1
• Pregabalin: Allows twice-daily dosing with superior bioavailability 1
• Gabapentin enacarbil: Prodrug formulation with improved pharmacokinetics 1

These agents have moderate certainty of evidence and avoid the augmentation risk inherent to dopamine agonists 1, 2

When Ropinirole Might Be Considered:

• Only for short-term use in patients who prioritize immediate symptom relief over long-term safety 1, 2
• Patient must be counseled about augmentation risk and monitored closely 2, 3
• Should not be used as first-line therapy 1, 2

Critical Pitfalls to Avoid

• Do not prescribe ropinirole without first attempting alpha-2-delta ligands unless there is a compelling contraindication 1, 2
• Do not increase ropinirole dose if symptoms worsen—this may indicate augmentation, not inadequate dosing 2, 3
• Do not abruptly discontinue ropinirole—taper gradually to avoid withdrawal symptoms 2
• If augmentation occurs, switch to alpha-2-delta ligands rather than increasing the dopamine agonist dose 2, 3

Practical Recommendation for Mental Health NPs

While you have the legal authority to prescribe ropinirole, you should prescribe gabapentin or pregabalin as first-line therapy for RLS based on 2025 American Academy of Sleep Medicine guidelines. 1, 2 If the patient specifically requests ropinirole or has failed alpha-2-delta ligands, document the discussion about augmentation risk and plan for close monitoring. 1, 2, 3

The scope-of-practice question is separate from the evidence-based practice question—you can prescribe it, but current guidelines say you shouldn't use it as standard first-line treatment. 1, 2, 3